Cut On The Dotted Line

Clearly I can’t leave well enough alone. This is just a quick link to an MSNBC article about FLDS parents driving hundreds of miles to see their children, as the sibling groups have been scattered to all corners of the Lone Star state. The FLDS spokesman claims to see something fishy in this, and although I’m more disposed to suspect any spokesman than I am the individual parents, I have to agree. Forget about the parents. Does anyone honestly think it’s good for children from tightly-knit families to be separated from their siblings? We’re talking about elementary-age children here. And again, why the big emphasis on keeping the mothers, not accused of any crime, away from the children, unless the real point of all of this is to reprogram them into proper modern children?

Just basic constitutional principles here. No one should be deprived of life or liberty without due process of law. Both children and parents here are being deprived of liberty, and with only a farce of a legal hearing so far. What kind of a precedent is this setting? What if the Arkansas authorities decide that being forced to grow up in a family of 18 children constitutes abuse, or brainwashing? Can they just go and confiscate the Duggars’ children? What about Amish children, brought up in isolation from the world, without simple amenities like electricity and TV? Should we forcibly assimilate them, distribute them through foster homes? What about homeschooled children? Back in the ’70s and early ’80s, they were indeed kidnapped away from their families, and parents spent weeks, even months in jail, for the crime of not conforming to the government-run school system. Maybe we should reopen this. They get spanked, after all, and taught all kinds of weird things: creationism, obedience to their parents (rather than teenage rebellion), the biblical perspective on all subjects, and forbidden to date. Maybe we need to move towards imitating the German government’s approach, where they recently put a teenaged girl in a mental asylum because her parents were brainwashing her by teaching her at home. (in case you thought the Germans had gotten over the fascist approach to the state’s privileges)

Whatever happened to the old-fashioned idea of burden of proof? Doesn’t the Texas government need to prove its allegations in order to keep these children locked up away from their mothers, brothers, and sisters?

Get a PDA of some kind, and put Epocrates on it. This free downloadable PDR gives all the essential information: drug names (brand and generic), indications, dosing, adjustments for renal/hepatic failure, side effects, contraindications, interactions, and pharmacology. There are also some nifty medical calculating gadgets that come with it, which will calculate FeNa for you, calculate equivalencies between different narcotics or steroids, and other mysterious details.

This program is tremendously useful for those times when, as usual, the patient gives you some funny spelling of their medication, or only knows the brand name and it’s a very tiny brand, or can’t remember the dosage. You can look up variations on the names, and find out what the usual doses are (if something only comes in 10 and 20mg, it’s very unlikely that they’re taking 300mg of it).

It’s also good for cancer patients being admitted for other reasons. The chief or attending will invariably ask what chemo regiment they’re on, and if you’ve run all the strange-lookings names on their med list through Epocrates, you can look brilliant by saying that they’re on X tyrosine-kinase inhibitor and Y mitogen inhibitor (which is usually used in advanced renal cell carcinoma, but has a new indication for this tumor).

There are some other good PDA applications, like the Johns Hopkins Antibiotic Guide (you can search by type of infection and bacteria involved, not just the name of the antibiotic), but to my mind Epocrates is the only really essential one. It’s gotten so ubiquitous that people really expect the interns and med students to have it available to solve problems with.

I’ve learned the geography for maybe 120 miles around my new city by dint of making polite conversation with my patients, and hearing that they live in such-and-such a city, ten miles east of X small country hospital, and two hours north of our place; and so on. Thus, my picture of the surrounding territory consists of outcroppings of towns labeled predominantly with the names of our referring hospitals.

The attendings and chiefs are a step ahead of me. They know not merely the hospitals, but the physicians who transfer patients to us regularly. In fact, they know them too well for their own happiness.

There’s one doctor in particular, I’m not sure yet whether he’s ER or a surgeon, but when the attendings hear his name (”Dr. Smith called about transferring a patient to your service”) an expression of disgust comes over their face, usually accompanied by several unprintable words. We’ve figured out, through too much experience, that when he bills a patient as stable and ok for a regular floor, we’d better prepare an ICU bed, and maybe have the OR on standby. Whereas when he describes a patient as septic, on death’s door, requiring urgent operation, we can safely order a regular floor bed, and consider whether a CT scan might suggest the need for surgery, or simply send the OR staff to bed. If he describes right upper quadrant pain, it’s invariably in the left lower quadrant. If he says the patient has no cardiac problems, they’re most likely in decompensated heart failure and/or infectious endocarditis. If he says a patient has necrotizing fasciitis, we can safely conclude that it’s simple cellulitis. If he says there’s a rigid abdomen, it’s sure to be as soft as a kitten.

The real problem is when he says he’s not sure what’s going on. Then we have nothing whasoever to base our conclusions on.

So my question is: was he always this poor of a doctor, or did he change after he left residency? If I’m a conscientious, careful resident, and learn how to accurately assess my patients, will that protect me from becoming this kind of terror to my colleagues? Or is it that once you leave the demanding academic environment, where there’s always someone looking over your shoulder and evaluating you, it’s just as easy to slip into this lackadaisical, “we’ll let the big hospital handle it,” mode? What can I do to keep myself from becoming this doctor?