How to tell you are married...

Our nightly bedtime ritual involves my husband lovingly putting a Breathe-right strip on my nose. (allegedly, I snore, though I'm not convinced) .

Before my LASIK surgery, I used to fall asleep next to my husband with my glasses on. Really sexy...

When I reach over to cuddle with my husband, I also try to sneak in his monthly testicular exam.

Hubby now feels perfectly comfortable to inform me that I look like a "car accident victim with a head injury" when I wake up in the morning. Granted I'm not a morning person and my AM conversation usually involves unintelligible monosyllabic grunts (hence the head injury part), and I guess I don't look so hot either.

I sleep with all 9 (yes, that's nine) of my stuffies (stuffed animals) at night and hubby doesn't complain. In fact he encourages this behavior by periodically adding to the collection. Thank goodness for our king size bed.

So all I want to say today is: Happy Anniversary honey, and thank you so much for the awesome new wallpaper!!!

PS: to celebrate our wedding anniversary, we are going on vacation and I will be out for the next two weeks. I will try to post if I have access to a computer, but I can't promise anything.

Gratis

I encountered a somewhat difficult patient the other day to whom I recommended a standard of care cystocopy as part of a hematuria (blood in the urine) workup. He proceeded to question everything I was doing and my decisions for doing so. I usually encourage these questions, but I had the sense that this patient was extremely anxious and was just talking himself into an even higher state of anxiety.

Finally, after all the relevant medical questions were exhausted, he asked me how much the procedure was going to cost, and I told him that "it depended but I could give him a ballpark figure". He then flew off the handle and ranted about how medicine is the only business where the key players don't know how much things are going to cost and how could such a business survive etc...

I gently corrected him by saying I knew very well how much my practice charges for the procedure, but how much he was actually going to pay out of pocket (and conversely what I would get paid) for the procedure depended entirely on his individual insurance plan, his co-pay and our contract with said insurance company. I can charge whatever I think is appropriate, but that does NOT mean I'm getting paid that amount due to the third party payer system we have here. The only people immune to this are plastic surgeons or other doctors who have a strict fee-for-service business and don't have to deal with insurance at all. They can post their fees openly because they will get what they ask, just like other regular businesses.

As his final trump card, he exclaimed: "well, what do you do for people who don't have insurance?", to which my immediate response was: "if it is medically necessary, then I would do it for free, and have done so many times.". My response seemed to subdue him, as if he had never thought of that possibility.

Indeed he was correct about one thing: there is no business like medicine. Who else would spend countless hours working (oft in the middle of the night) with patients euphemistically referred as "self-pay" knowing full well that they will not get paid at all? Your lawyer? Your plumber? Your favorite movie actor? I dare say nay. I honestly cannot think of many examples, yet almost all of the physicians I know do pro bono work frequently; it's just another part of being a physician in the 21st century...

Six word memoir meme

I'm very late in the game as this meme came out a few weeks ago, but I got tagged by Seaspray, and since I've let her down so many times before, I thought I would give this one a try.

The Rules are:
1. Write your own six word memoir.
2. Post it on your blog and include a visual illustration if you want.
3. Link to the person that tagged you in your post and to the original post if possible so we can track it as it travels across the blogosphere.
4. Tag at least five more blogs with links.
5. Leave a comment on the tagged blogs with an invitation to play.

I've been very busy these past few weeks, to the extent that I've even had to do an elective surgery this saturday (my off day since I'm not even on call!) because my regular weekday schedule has been triple booked....

So I was tempted to write something pithy like:

Sacrificing saturday for nephrolithiasis is worthwhile

But after some thought, I came up with:

Personal and professional life? Never dull.

Vocabulary lesson

Presenting some new medical verbiage in the field of urology, as introduced to me by numerous patients:

Prostrate:
Male gland that likes to worship face down on the ground. Frankly it makes me feel uncomfortable when I encounter it because my god complex is not that highly developed.

Sphinxter:
Enigmatic yet strong lion-like little muscle in control of certain nether functions. May have egyptian etymology.

Urether:
In-betwixt a urethra and a ureter! It transports urine directly from the kidney straight out into the toilet!

Blatter:
Can be used to store and hold urine, as well as carry food on special occasions.

Penes:
A multi-purpose instrument. Urination, reproduction, calligraphy...

Information overload

We are required by law to give an informed consent on any medical procedure/surgery we perform. This involves explaining in detail what the procedure is, what the risks and benefits are, and what other alternatives are available for treating the ailment. It's something we are taught to do very early on in our career, not only because it's a requirement, but it's also the correct course of action in order for the patient to make an informed decision about his/her medical care. Should you fail to do so, not only would you be deemed a bad doctor, but there are many unpleasant legal ramifications that can await you...

I take care to go into great detail about each surgery I am about the perform. I really want the patient to understand exactly what is going to happen, what the expectations are after surgery, and all the potential risks attributable to the surgery.

The questions is: when is it too much information?

My answer is NEVER, but there are many times when I feel like I am really putting the patient off by describing too many "gory" details. For example, when I describe a ureteroscopy with a stent placement to a male patient with a stone, I have to tell him that I am going to place a long thin scope up into his penis, find his ureteral orifice, go up the ureter to find the stone and laser it, then end the procedure by leaving a long plastic tube inside that will span his entire ureter from the kidney to the bladder. Albeit all under general anesthesia, but I can usually see the patient physically wince and cross his legs... and this is even before I go into all the potential risks and complications from the procedure...

But what else can I do? The patients needs to know, and I want them to know. That's part of practicing medicine in the 21st century. Gone are the paternal days of medicine when the doctor decided what was best for the patient without any questions asked.

I've changed my middle name

I've come to realize that I have become increasingly obsessive-compulsive in my old age. I don't know exactly when this change occured, but I can assure you that I wasn't born this way. Procrastination was my middle name. Growing up, I always did my homework at the last minute, waited until the very end to send in college applications and always pulled all-nighters to finish up papers and other assignments due to poor time management. Medical school wasn't much of an improvement, and the lack of sleep and constant fatigue during residency ensured that I rarely did anything ahead of time. Utility bills were often paid late and I once had my water shut off because I wasn't home enough or even cared enough to dig through the mail. I could hardly call myself a very organized person.

However, I've had an almost 180 degree change in character since starting my practice. Some might even call me "anal" these days and I would not dispute that description. Certain facts indubitably point to this metamorphosis:

- I've already submitted my tax return for 2007.... one month ago.
- I check labs and vital signs on my inpatients from home every night even though one of my partner is on call.
- I pack for trips on the eve of my departure. (trust me, huge improvement!)
- I try on outfits and pack for longer trips at least 3 days before departure day.
- I brush my dogs teeth almost every day.
- I brush my own teeth BID. OK, I've always done that, but some might consider that "anal".
- The cat gets a manicure/pedicure (by me) once every two weeks. Actually, so do the dogs.
- I frequently wake up before the alarm clock goes off.
- I set my alarm clocks on weekends... even when I'm not on call.
- I arrive to appointments on time, often even a few minutes early.
- I get really annoyed when other people are late.
- Online bill pay has ensured that I pay 100% of my bills 100% on time. But I still check.
- I know when my next haircut will be (May 24th if you were curious)

Is this enough proof? The scary thing is that I could go on...Why have I turned into a Blackberry?

Perhaps it's because I have lost the "student mentality" and feel more like a responsible member of society. Perhaps it's that electric jolt I got at work from a defective toaster a few years ago. Perhaps it's the core strength finally going to my head after years of Pilates. I don't really have an answer, but in any case, I want to believe this change is for the better.

PS: I'll write again in exactly 5 days 9 hours and 35 minutes. See you then...

Please don't press that button

PCA (Patient Controlled Analgesia) is a godsend for most patients and nurses. It's a pump attached to your IV that contains your narcotic of choice (usually morphine or dilaudid), and by pressing a button whenever you need it, you are able to get a preset amount of pain med into your system.

You can order the settings in a variety of ways, from the dose of each pain med, to how often it can be administered, to a four hour maximum dose limit. This way, no matter how many times a patient pushes on the button, you only get a certain set amount, and very rarely do you see overdoses. And if you don't need any pain meds, you just don't push on the button. Simple as that.

I almost always use a PCA pump for my post-operative patients. This way, they don't have to call the nurse and wait for them to come around with pain meds. My standard setting is 1mg morphine every 8 mins, with the ability to increase to 2mg q8 mins if necessary, with 20mg to 30 mg maximum 4 hour dosage. I don't like continuous delivery settings because frankly, I don't think it's safe. Naturally I adjust accordingly to the size of the patient and other medical factors.

The system usually works beautifully. The patients are in charge of one aspect of their care, which is so important in a hospital environment where they usually feels as though they have relinquished all control of their lives. In addition, the immediate relief of the surgical pain can really help in the post-operative course. The whole concept of a PCA works when the patient is the one pushing the button whenever there is a need.

The system goes awry when well-intentioned family members want the patient to feel as comfortable as possible, and will push the PCA button for him/her, even when the patient is asleep or not in any obvious pain. The family will keep a vigil over the patient's every single facial expression, and if there is a suspicion of an involuntary grimace, or a little moan that escapes during the nap, they will press the button. Certainly well-meaning, but probably not the wisest course of action especially when the patient goes into respiratory depression and Narcan has to be administered rapidly.

Just call me Bozo

For those of you who don't give a hoot about women's hair issues, you can stop reading now. This post is for the 51% of the population who can commiserate with me. I had a somewhat eventful trip to my hair stylist yesterday whom I love and who usually does a top-notch job. She just returned from an 8 month hiatus and had been sorely missed. Since I was overjoyed at seeing her again, I decided to entrust fully in her artistic flair and became putty in her capable hands. She cut my hair to perfection, but when I mentioned I wanted "vibrant highlights" in my hair, she interpreted this to mean "fiery orange-red".

To my dismay, as I stepped out of the salon, my hair actually glowed in the sunlight. I admit that the effect was rather striking, and would have been perfect had I worked in a creative field such as advertising, designing, or even at the circus. Alas, the medical world is rather conservative, and I didn't know how my colleagues and more importantly how my patients would react to such a innovative hair color. Perhaps things would have been a tad easier had I been a pediatrician, since kids tend to like clowns....

I decided to see if my hair would magically tone itself down during the wondrous process of sleep restoration, but when I woke up this morning, the combination of orange-red with bed hair did little to calm my disquietude. Again, perfect if I were working at an art gallery expounding on the juxtaposition of the artist's angst and loneliness demonstrated by his use of color and stippling effects throughout the canvas. However, not ideal if I'm trying to instill confidence in Mrs Jones so I can operate on her kidney stones.

Thankfully husband extraordinaire saved the day. He did a lot of research online about "hair coloring gone wrong" (I can attest that there is a TON of information on this subject!) and "consulted" with "le couleur expert" Christophe from L'Oreal's website (a great interactive tool where you can plug in your questions, and Christophe will magically devise a solution). We went to our local drugstore and purchased the recommended subduing color. Husband applied the stuff while I prayed outloud and 30 minutes later, the results far surpassed my expectations! I had great color with perfect highlights!!!

Smug and proud of it.

At the risk of sounding extremely smug and self-satisfied, I have to tell you that I had a very productive Saturday morning this past weekend. Alas, I happened to be on-call, and there were several patients at different hospitals that needed to be seen, in addition to new consults and procedures to be done.

Nevertheless, before 11:00 AM, I was able to:

-Wake up at 6:45 AM. (Come on! Remember that this was a SATURDAY... this should be considered a major achievement already!!!!)

-See a trauma consult for a bladder rupture and meatal stenosis (tightness at the opening of the urethra, making insertion of a foley catheter impossible). I reviewed the CT scan, evaluated the patient, dilated his urethra (some might say 'tortured with barbaric instruments") and placed a foley. Thankfully the ICU nurse was kind enough to give the patient ample amounts of morphine and versed.

-Round on the patients at that hospital and write semi-legible notes and orders.

-"Speak" to a Russian-only speaking inpatient. Through a combination of slow english, bad russian (from my residency days), miming, facial and body contortions, I was able to make myself understood. I discharged her from the hospital and arranged for follow-up with my partner. (at last, those acting classes taken during high school extracurricular activities are finally paying off!!!!)

-Crush and stamp out a painful kidney stone via a ureteroscopy with holmium laser lithotripsy in the OR.

-Eat a banana and drink a latte in under 2 minutes flat while driving over to a second hospital.

-See a fresh post-op patient in the ICU of above mentioned hospital.

-Rush over to a third hospital whilst avoiding any speeding tickets to see a couple more patients. Wrote illegible chicken scratch notes. Spoke to many nurses. Resisted the temptation to nibble at the most enticing chocolate-frosted donut in the staff lounge. (Probably the proudest achievement of my day)

-Stop by my favorite frozen yogurt place for THE most amazing honey frozen yogurt. Tart, just slightly sweet with a hint of honey, and fat-free!!! This is a weekly saturday pit stop, whether I'm on call or not.

-Returned home to kiss my dogs, cat and hubby. (in that order!)

Lunar Eclipse

Was anyone else able to catch a view of the lunar eclipse last night? It was quite amazing! I was worried that clouds would obscure our view, but it was an unusually clear night, and the event was wonderous.

We have a telescope that I bought as one of my better christmas present for hubby several moons ago, that is now mainly used as a decorative accent to our living space. I always feel like Jimmy Stewart from "Rear Window" when I look through it, but this was the perfect opportunity to use it as it was originally intended. The shadow of the earth eclipsing the moon is a sight to behold!