"The absolute worst thing is seeing a woman come in pregnant..."

Yeah, that just happened. The above title is from a conversation I had today with one of the staff at the GYN clinic I'm stationed at for the next month. Taken out of context? How can you take that comment out of context?! But for completeness sakes, no its not out of context.

To their defense, this person, and the clinic as a whole, is openly pro-choice. I, or you, might disagree with this (or agree), but nonetheless I believe it important to respect the decision that has been come to.... however wrong. For on the flip-side, I want my beliefs to be respected, even if they are disagreed with. Please tell me though, when did having a kid become such an unbearable burden?! Truly they are a large responsibility, but what an awesome responsibility it is - your shaping the future! I can't help but being reminded of a movie I saw recently, Children of Men. If you haven't seen this movie, rent it. Regardless of your thoughts on the fiery subject of reproductive rights it paints a scary picture of a future where man has essentially extincted himself. Not that we are there or heading in that direction, but it makes you think that maybe we should be respecting human life just a little more than we do.

It is going to be an interesting month to say the least.

Who Me?!

In my opinion, its very easy to become jaded in medicine through the long hours, reality of death, ungrateful patients, and the revolving hospital door of non-compliant patients. I am probably listing only a few of the myriad mechanisms, and likely only those that I have myself experienced. Recently I cared for a young patient, 30's, who had received a heart transplant a number of years ago. She came into the hospital because she was acutely having chest pain, was admitted to the Cards service and stabilized on the floor. Promptly, the next morning, she coded. Since I was a resident in the Cardiac ICU and she was a cardiac floor patient, myself and my resident ran to the code.

We arrived to find her in PEA (pulseless electrical activity), which isn't important except for two things: 1) that type of code has notoriously bad outcomes and 2) there are certain things (7-8) that cause PEA. The residents and nurses at the code, including myself, immediately and hurriedly began CPR, tubed her (intubated), and reasoned our way through the etiologies of PEA to determine how to correct this situation. After about 10 minutes, the patient had a pulse and became arousable. She was transferred to the CCU and within 5 minutes of arrival, coded again. This particular code lingered on for approximately 20-25 minutes and were within seconds of 'calling it,' but noted she amazingly had a pulse... albeit on 4 pressors and 1 inotrope.

Fast forward a week. Extubated, off all pressors, fully awake, aware, and neurologically intact, and the most difficult patient I have ever cared for. Nothing was right for her, she complained about everything. This hurt, that hurt, she didn't want her blood drawn, she wanted to check her email, she wanted ice cream, on and on and on. Nevermind the fact that she was still alive, nope that wasn't good enough.

Why the story? A simple contrast. Weeks before I had cared for a very nice older gentleman. He honestly didn't need to come into the hospital, but nevertheless was admitted. There was delay after delay and he stayed for 3 days, when it needed only be 1. I could tell he was frustrated, but he never voiced it and a few days after his discharge I received this email:

---

Dear Dr. ********,

Thank you for taking the time to work me into your busy schedule. I know
what a busy person you are and I am very appreciative for the time you took
to see me.

After I checked into the hospital I was seen by Dr. ********** and Dr.
Mandichak on your staff and they did an excellent job of reviewing my case
and providing a constructive course of action. I was very impressed by the
skill of these two Drs., by attention to detail and by their interpersonal
manner. I am feeling much better and I feel I am finally on the road to a
full recovery. I could not have been more pleased with my treatment by you
and the aforementioned Drs.

With best wishes,

****
---
I have taken out the other names so I don't get sued for violating HIPPA. The contrast between these two patients is striking. It has also struck me, how quickly I forget about all the pleasant and cooperative patients I care for and often immediately focus on the more troubling ones. I'm trying not to become jaded, but at times I think that is only a dream.

Ethics was never my strongpoint....

Well, folks, it finally happened! And it only took 4 months! Let me explain... Many of you probably know my aversion to the historically intimate relationship between big pharm and the medical profession. Let me not be misunderstood, I - as much as anyone - love free stuff such as expensive dinners, CME credits in Hawaii, front row seats, and the ever ubiquitous pen. But as much we doctors deluded ourselves to thinking such freebies do not change our prescribing patterns, we're wrong. It does and multiple studies confirm it.

Sooooo, that being said, I stand before you the new recipient of the Mayo Clinic Internal Medicine Review - free of course. Obviously my bark is then much stronger than my bite. I make the excuse that fundamentally my acceptance of such a gift is purely educational. By taking the book, reading it, and employing that which I've read, I will make medical decisions based upon evidenced based outcomes.... right?! Surely, I am not ethically challenged enough to prescribe Plavix in situations where it's efficacy isn't proven. Well, honestly, that is a question we'll never know the answer to.

I fear I have engaged a slippery slope.