Most cities have a list of the best doctors...or lawyers, or dentists, or architects, etc. Instead I suggest that we publish the worst doctors.
First, I have to admit that I haven't been the best at anything that I have done. I also know that even if I am good at what I do there will always be somebody, somewhere, better at it than me, even if I was considered the best in my confined area. This the law of the West, where there is always a better gun, and the rest of the world. So I have become resigned to being a strong person at what I do but not the best. But the best also seems rather hard to define in such a deep and complicated field as medicine...or law, or architecture, or any adult profession except professional sports where winning is the definition of success.
Look at it this way, the best doctors have become that way because they have been in practice long enough to establish a reputation with patients and other medical professionals. But this means that they have already been receiving a number of referrals that have left patients and referring physicians impressed with their work. And they are probably quite good at what they do, so this means there are already a number of patients clamoring for their services and you could wait until your dead until you see them, or be referred to one of their partners, which kind of defeats the purpose of the list. I tried to get into a gastroenterologist (age 50=colonoscopy) that was one of Seattle's best and was told that I couldn't see him for about six months. By then I could have cancer and be dead, or at least vomiting blood, or having other messy problems, that would leave me unsatisfied. If I wanted this I could try to find a doctor in Canada or, God forbid, in England (sarcasm marker here).
Instead why not list the worst doctors in the community. At least this would allow one to know who not to see, and it would allow the unknowing to get an appointment in a reasonable time frame with a perfectly fine doctor. Maybe they wouldn't be the best but they wouldn't be the worst either. If you believe in lists, somewhere tomorrow, a patient will be walking into the office of the worst physician in the nation (thanks John Robinson). I would rather avoid this than wait 6 months to see the best.
This is meant to be tongue in cheek since I think the legal ramifications for any publication to take this on would be huge, but it also isn't without merit because doctors and nurse, those usually polled for these Best Of... lists, also know who not to see. Perhaps when a friend or family member asks who to see in the community we, as doctors and nurses, should tell them who not to see instead.
Sunday, September 26, 2010
Sunday, September 5, 2010
Hole and Weezer: The Bands
Before getting to the day's events I'll convey some Woody Allen lines: 1) Intellectuals have proven you can be absolutely brilliant and still have no idea what's going on, and 2) A patient says to his doctor, "Doc, I think my brother is crazy, he thinks he's a chicken." The doc says, "Well why don't you turn him in?" The patient says, "I would but I need the eggs." Somewhere in Woody Allen there is philosophy.
I spent the weekend watching monitors in the electronic ICU of Swedish Hospital in Seattle. This is my transition job while I ease myself back into the clinical world. I managed a patient over a visual monitor and loudspeaker for an hour last night, he eventually died. It is a bit surreal to watch someone die on television, for real, especially when it's a consequence of unsuccessful interventions from you, sitting watching a monitor of the patient, writing orders into a computer and interacting with nurses who can only hear my voice from the ceiling.
I got home this morning and watched the Sunday morning news shows to defervesce. Christiane Amanpour interviewed Tony Blair on ABC's This Week. They were both witty, intelligent and likable. He commented that he still gets butterflies on Wednesdays, a day when, during his time as PM of England, he had to stand and deliver on Prime Minister's questions at Parliament. Although I can understand I had not realized that it was such a nerve racking thing for him. On the PBS broadcasts of the events he seemed so poised and in control, even enjoying it.
I got some sleep in the afternoon and went to Bumbershoot, a music festival in Seattle held every Labor Day weekend in the evening. This is what I want to talk about most since I got to see Hole and Weezer in concert this evening. I have not been to a rock concert for years and have to admit it was not like rock concerts I remember as a kid. My most memorable concert was the Rolling Stones concert I went to in high school with my friend Pat Gleason. We snuck into the concert by holding cutout cardboard tickets that we held in line until we got to the ticket takers. When they looked down to take our fake tickets we bolted into the St. Paul Civic Center, I ran into someone carrying beers and splashed them in my wake while running onto the concert floor. A hooligan without a violent streak maybe, but it was worth it since the concert was sold out. And everything seemed so crazy then anyway. The Stones were about an hour or two late to come on stage. The whole place was blue with pot smoke and my friend Larry Olson, who paid top dollar for his tickets, passed out under the seats right as Mick Jagger came onto the stage. He didn't wake up for the whole concert. After, the crowd toppled some police cars and St. Paul banned rock concerts for a few years. That's the kind of concerts I remember.
Bumbershoot is an annual celebration in Seattle held over Labor Day weekend. It brings an array of bands, from big names to local acts, and has food stands and face painting, etcetera. The main stage tonight had Courtney Love and Hole as well as Weezer. They were both cool in different ways. Although Courtney Love is a psychological marsh, by reputation, she makes good music. Wikepedia reports that she was raised in communes in Oregon, that her father gave her LSD when she was 3 years old and that she will be an heir to the Bausch and Lomb eye care fortune when her mother dies. She was the wife of Kurt Cobain and was sued by the remaining members of Nirvana. She also reformed Hole without the contractually necessary consent of co-founder Eric Erlandson, they officially disbanded in 2002, which suggests there will be more business fun to come in her life. Apparently in Spin magazine Eric Erlandson said something to the effect of, "She can't do that".
I got to the stage early so was able to get up close. This didn't matter for Holes' performance since not many people showed for that but it did make for a "mosh" when Weezer came on. Courtney Love didn't seem frankly psycho during Holes' performance but she did have her moments. She wore a dress and repeatedly put her foot up on a speaker monitor leaving her crotch exposed during the show. I am happy to report that she did wear underwear. She smoked during the performance and at one point stopped a song and asked for a cigarette from one of the stage hands. She also commented alluded to Kurt Cobain's death, he shot himself, by saying, "1-7-1 Lake Washington Boulevard...Wow!" This was the address where he was found dead, kinda without a head. That same day in April 1994 was my first day, visiting from New York, in the Seattle area and I remember hearing a DJ on 107/The End breaking the story.
After Courtney L. stopped gazing at the Space Needle looming over the stage like a nun behind a misbehaving school kid she left the stage without much affair. Seattle, a place she referred to as home as in "Hello Home...", doesn't seem to like her very much. I think it's because she smokes, or because she screwed (legally) the remaining members of Nirvana, or just because she didn't have a tight set tonight, who knows. I think Europe likes her.
Then the All American boys came on. Weezer has some good singles but I never knew that they were such a cult band. The stage area filled in hugely before they came on and the crowd started to move and undulate even before they came on. It was all good natured and because I was so close and so tall I started to get some jabs from kids behind me. But even that was all good since it wasn't mean stuff. The Weezer fans were of a younger generation than mine but they were cool.
The lead singer/songwriter is named Rivers Cuomo and he was "on" tonight. He looks like a cross between Woody Allen and Elvis Costello with a yamika balding spot and black framed glasses. He wore a pink Polo shirt under a stripped rugby sweater with jeans and white tennis shoes. He walked like a duck but acted like Mick Jagger. And he was all over the arena! He climbed the scaffolding of the set and with wireless technology sang from different areas of the arena with a spotlight picking him up wherever he went. The rest of the band was muscular and tight and very cool. It was invigorating to see and hear.
During a couple of the hits, "People say, Rivers, why don't you sing the hits? Rivers why not sing the hits?..." Well he did, and the crowd was crazy. The spectacular part of it was being so close to the stage and seeing the undulating arms like cilia waving and moving kids that were thrown up and moved on the wave of hands to the front of the crowd. I guess since I looked strong enough I had a kid tap me on the shoulder to ask if I would throw him up. I cupped my hands, he put a foot in and I hoisted him up onto the hands and away he went. It was very cool to have a ground level view of this. He just got carried away on the undulating hands, laughing with his limbs moving all akimbo. Since the first try was successful another asked me to do it, then another. The last kid was an Asian girl with braces all of about 15. She asked, "Can you do that to me?" and I have her face burned into memory since she seemed so sweet and so ready for the ride, like an excited kid at the fair ready to get on the roller coaster. She was the last one I hoisted onto the swaying arms and as she drifted away on her back, on the hands, she giggled intensely until she was gone. What a vision. All the while Weezer was cranking the music and the crowd was swaying and the kids on top were giggling and full of fun. I walked out of the concert a new man for awhile since I hadn't had so much fun for a long time.
Music can be intoxicating and Weezer was an intoxicating band. Bumbershoot was a success with me and Seattle gets credit in my mind for sponsoring such a good event. Good on ya Seattle.
I spent the weekend watching monitors in the electronic ICU of Swedish Hospital in Seattle. This is my transition job while I ease myself back into the clinical world. I managed a patient over a visual monitor and loudspeaker for an hour last night, he eventually died. It is a bit surreal to watch someone die on television, for real, especially when it's a consequence of unsuccessful interventions from you, sitting watching a monitor of the patient, writing orders into a computer and interacting with nurses who can only hear my voice from the ceiling.
I got home this morning and watched the Sunday morning news shows to defervesce. Christiane Amanpour interviewed Tony Blair on ABC's This Week. They were both witty, intelligent and likable. He commented that he still gets butterflies on Wednesdays, a day when, during his time as PM of England, he had to stand and deliver on Prime Minister's questions at Parliament. Although I can understand I had not realized that it was such a nerve racking thing for him. On the PBS broadcasts of the events he seemed so poised and in control, even enjoying it.
I got some sleep in the afternoon and went to Bumbershoot, a music festival in Seattle held every Labor Day weekend in the evening. This is what I want to talk about most since I got to see Hole and Weezer in concert this evening. I have not been to a rock concert for years and have to admit it was not like rock concerts I remember as a kid. My most memorable concert was the Rolling Stones concert I went to in high school with my friend Pat Gleason. We snuck into the concert by holding cutout cardboard tickets that we held in line until we got to the ticket takers. When they looked down to take our fake tickets we bolted into the St. Paul Civic Center, I ran into someone carrying beers and splashed them in my wake while running onto the concert floor. A hooligan without a violent streak maybe, but it was worth it since the concert was sold out. And everything seemed so crazy then anyway. The Stones were about an hour or two late to come on stage. The whole place was blue with pot smoke and my friend Larry Olson, who paid top dollar for his tickets, passed out under the seats right as Mick Jagger came onto the stage. He didn't wake up for the whole concert. After, the crowd toppled some police cars and St. Paul banned rock concerts for a few years. That's the kind of concerts I remember.
Bumbershoot is an annual celebration in Seattle held over Labor Day weekend. It brings an array of bands, from big names to local acts, and has food stands and face painting, etcetera. The main stage tonight had Courtney Love and Hole as well as Weezer. They were both cool in different ways. Although Courtney Love is a psychological marsh, by reputation, she makes good music. Wikepedia reports that she was raised in communes in Oregon, that her father gave her LSD when she was 3 years old and that she will be an heir to the Bausch and Lomb eye care fortune when her mother dies. She was the wife of Kurt Cobain and was sued by the remaining members of Nirvana. She also reformed Hole without the contractually necessary consent of co-founder Eric Erlandson, they officially disbanded in 2002, which suggests there will be more business fun to come in her life. Apparently in Spin magazine Eric Erlandson said something to the effect of, "She can't do that".
I got to the stage early so was able to get up close. This didn't matter for Holes' performance since not many people showed for that but it did make for a "mosh" when Weezer came on. Courtney Love didn't seem frankly psycho during Holes' performance but she did have her moments. She wore a dress and repeatedly put her foot up on a speaker monitor leaving her crotch exposed during the show. I am happy to report that she did wear underwear. She smoked during the performance and at one point stopped a song and asked for a cigarette from one of the stage hands. She also commented alluded to Kurt Cobain's death, he shot himself, by saying, "1-7-1 Lake Washington Boulevard...Wow!" This was the address where he was found dead, kinda without a head. That same day in April 1994 was my first day, visiting from New York, in the Seattle area and I remember hearing a DJ on 107/The End breaking the story.
After Courtney L. stopped gazing at the Space Needle looming over the stage like a nun behind a misbehaving school kid she left the stage without much affair. Seattle, a place she referred to as home as in "Hello Home...", doesn't seem to like her very much. I think it's because she smokes, or because she screwed (legally) the remaining members of Nirvana, or just because she didn't have a tight set tonight, who knows. I think Europe likes her.
Then the All American boys came on. Weezer has some good singles but I never knew that they were such a cult band. The stage area filled in hugely before they came on and the crowd started to move and undulate even before they came on. It was all good natured and because I was so close and so tall I started to get some jabs from kids behind me. But even that was all good since it wasn't mean stuff. The Weezer fans were of a younger generation than mine but they were cool.
The lead singer/songwriter is named Rivers Cuomo and he was "on" tonight. He looks like a cross between Woody Allen and Elvis Costello with a yamika balding spot and black framed glasses. He wore a pink Polo shirt under a stripped rugby sweater with jeans and white tennis shoes. He walked like a duck but acted like Mick Jagger. And he was all over the arena! He climbed the scaffolding of the set and with wireless technology sang from different areas of the arena with a spotlight picking him up wherever he went. The rest of the band was muscular and tight and very cool. It was invigorating to see and hear.
During a couple of the hits, "People say, Rivers, why don't you sing the hits? Rivers why not sing the hits?..." Well he did, and the crowd was crazy. The spectacular part of it was being so close to the stage and seeing the undulating arms like cilia waving and moving kids that were thrown up and moved on the wave of hands to the front of the crowd. I guess since I looked strong enough I had a kid tap me on the shoulder to ask if I would throw him up. I cupped my hands, he put a foot in and I hoisted him up onto the hands and away he went. It was very cool to have a ground level view of this. He just got carried away on the undulating hands, laughing with his limbs moving all akimbo. Since the first try was successful another asked me to do it, then another. The last kid was an Asian girl with braces all of about 15. She asked, "Can you do that to me?" and I have her face burned into memory since she seemed so sweet and so ready for the ride, like an excited kid at the fair ready to get on the roller coaster. She was the last one I hoisted onto the swaying arms and as she drifted away on her back, on the hands, she giggled intensely until she was gone. What a vision. All the while Weezer was cranking the music and the crowd was swaying and the kids on top were giggling and full of fun. I walked out of the concert a new man for awhile since I hadn't had so much fun for a long time.
Music can be intoxicating and Weezer was an intoxicating band. Bumbershoot was a success with me and Seattle gets credit in my mind for sponsoring such a good event. Good on ya Seattle.
Saturday, August 28, 2010
How can we die of a broken heart? The physiology.
Back to a less controversial subject, how we die from a broken heart. The syndrome of Takotsubo's cardiomyopathy is interesting since it may account for the death of people who are so upset about a subject for a length of time that they actually die, much like we sometimes see when patients die soon after the passing of a loved one. Takotsubo's was first described in Japan thus it got its name, tako tsubo or octopus trap. An octopus trap is shaped such that the octopus can crawl in the trap but can't get out. It is like a wine carafe where the neck is narrow and the decanter is broad. This is what happens to the heart when someone has a lot of adrenaline floating in their system from stress, the outlet of the heart can remain narrow as the body of the heart becomes bulbous, making it difficult to emit blood. On angiogram the coronary vessels appear normal but there may be a correlation with the length of the front coronary artery, the left anterior descending artery, and risk of developing takotsubos cardiomyopathy. From the adrenaline there may be microvascular obstruction to blood flow in parts of the heart that are important for emitting blood. Patients often present with symptoms of a heart attack but can sometimes present with heart failure for otherwise unknown reasons. The treatment is with beta blockers or calcium channel blockers which can alter the strength of heart contractions and protect the heart from detrimental effects of adrenaline. This is how one could die from a broken heart.
Thursday, August 19, 2010
Zoo Seattle
This will be a dark blog today. Last night I watched a documentary called Zoo, "an extraordinary glimpse into the life of a seemingly normal Seattle family man whose secret sexual appetites led to his shocking death". Basically this guy was being screwed by a horse who perforated his sigmoid colon and the guy died of peritonitis. The documentary was shown at the Sundance Film Festival in 2007. My nurse Janet gave it to me awhile ago since we had discussions of the event but I have been hesitant to watch it. The documentary interviews those involved with the secret taping of men having their way with farm animals in the fields of Washington and it seems to dramatize some events with actors. I didn't know what was real and what was staged with actors, but I do know it was the weirdest thing I have seen in some time.
The guy who died was a Boeing engineer and at least one of the perpetrators emigrated from West Virginia. During his bus ride we got to hear his reflective thoughts about of zoophobia. "It's like I really care for the animals". But these guys were sneaking onto the property of others in the middle of the night to have their way with the animals of other people, and they filmed it, and put it on the internet. There were no laws against this practice in Washington State so although there were arrests made the only charges rendered were for trespassing. Animal Rights reps were suggesting that the horses were being taken advantage of but for the first time in my life I agree with Rush Limbaugh, who was arguing on tape that the horse had to be a willing partner in this so it seemed unlikely there was animal abuse. But maybe there is a Mary Kay Letourneau argument here, another Seattle curve ball, regarding a woman who had an affair with her 12 year old student and eventually had two children by him while in jail (huh?). She was arrested and convicted for having sex with a minor but is it rape since he had to be a willing character? I guess so. By this argument it seems wrong that the horse would be put into a situation of being tempted by the pheromones of the man they referred to in the documentary as "Mr. Hands". There are now bestiality laws in Washington State so all you guys hoping for some poke outside the local Starbucks can find something else to do. Maybe the bathrooms at the Minneapolis/St. Paul airport...the Larry Craig (R-Idaho) Memorial Stall is waiting.
So in one of the interviews an organizer of the Zoo or Fun in the Fields suggested that he was an innocent. He was astonished when the County Sheriffs came to get him. As he stated, "I don't see myself as a bad person, I love these animals" but he sure took off when the cops showed up at his door.
A patient of mine in Bellingham had such bad scoliosis that he couldn't breathe but when I told him that his shortness of breath emanated from his severe scoliosis he told me that he "didn't have scoliosis" and stormed out angry. Another patient got angry when I told her she had emphysema, and when she inhaled a peanut in Miami she told me that she wouldn't pay my bill because I had missed a peanut in her lungs that was causing her shortness of breath, not emphysema. I was an idiot. But she did have bad emphysema and she was still short of breath despite the removal of the transient peanut.
Yesterday the New York Times published an article on Alaska. Alaskans were recorded saying that they wanted government out of their life, but when told that Alaska gets the most per capita distribution of money of all the states from Washington D.C. they will say, "Yeh, we sure do get a lot of money from the federal government". What is this all about?!
I have persistently encountered some weirdly contradictory and self-centered individuals that just do not frame the social world in a fashion that's understandable. Maybe this is what the Middle Ages were like.
After living in the Pacific Northwest for about fifteen years I have outlined an analogy that I want to get record: when one encounters a porcupine in the forest one tends to avoid it and each party is happy. But when a porcupine appears like a cuddly house cat and you pick it up and you get "porcupined", this is distressing. Not only that but if you cry out, "You're a porcupine and not a cute, cuddly cat" and the porcupine says, " I'm not a porcupine!" Then it's time to leave the forest that has porcupines made up like cats who don't know they're porcupines. Or at least take some pill that will calm the inner weird meter. Do the guys who screw horses and place the video on the internet really love animals? They don't act that way but they may truly feel that way.
The guy who died was a Boeing engineer and at least one of the perpetrators emigrated from West Virginia. During his bus ride we got to hear his reflective thoughts about of zoophobia. "It's like I really care for the animals". But these guys were sneaking onto the property of others in the middle of the night to have their way with the animals of other people, and they filmed it, and put it on the internet. There were no laws against this practice in Washington State so although there were arrests made the only charges rendered were for trespassing. Animal Rights reps were suggesting that the horses were being taken advantage of but for the first time in my life I agree with Rush Limbaugh, who was arguing on tape that the horse had to be a willing partner in this so it seemed unlikely there was animal abuse. But maybe there is a Mary Kay Letourneau argument here, another Seattle curve ball, regarding a woman who had an affair with her 12 year old student and eventually had two children by him while in jail (huh?). She was arrested and convicted for having sex with a minor but is it rape since he had to be a willing character? I guess so. By this argument it seems wrong that the horse would be put into a situation of being tempted by the pheromones of the man they referred to in the documentary as "Mr. Hands". There are now bestiality laws in Washington State so all you guys hoping for some poke outside the local Starbucks can find something else to do. Maybe the bathrooms at the Minneapolis/St. Paul airport...the Larry Craig (R-Idaho) Memorial Stall is waiting.
So in one of the interviews an organizer of the Zoo or Fun in the Fields suggested that he was an innocent. He was astonished when the County Sheriffs came to get him. As he stated, "I don't see myself as a bad person, I love these animals" but he sure took off when the cops showed up at his door.
A patient of mine in Bellingham had such bad scoliosis that he couldn't breathe but when I told him that his shortness of breath emanated from his severe scoliosis he told me that he "didn't have scoliosis" and stormed out angry. Another patient got angry when I told her she had emphysema, and when she inhaled a peanut in Miami she told me that she wouldn't pay my bill because I had missed a peanut in her lungs that was causing her shortness of breath, not emphysema. I was an idiot. But she did have bad emphysema and she was still short of breath despite the removal of the transient peanut.
Yesterday the New York Times published an article on Alaska. Alaskans were recorded saying that they wanted government out of their life, but when told that Alaska gets the most per capita distribution of money of all the states from Washington D.C. they will say, "Yeh, we sure do get a lot of money from the federal government". What is this all about?!
I have persistently encountered some weirdly contradictory and self-centered individuals that just do not frame the social world in a fashion that's understandable. Maybe this is what the Middle Ages were like.
After living in the Pacific Northwest for about fifteen years I have outlined an analogy that I want to get record: when one encounters a porcupine in the forest one tends to avoid it and each party is happy. But when a porcupine appears like a cuddly house cat and you pick it up and you get "porcupined", this is distressing. Not only that but if you cry out, "You're a porcupine and not a cute, cuddly cat" and the porcupine says, " I'm not a porcupine!" Then it's time to leave the forest that has porcupines made up like cats who don't know they're porcupines. Or at least take some pill that will calm the inner weird meter. Do the guys who screw horses and place the video on the internet really love animals? They don't act that way but they may truly feel that way.
Thursday, July 29, 2010
Nurse-doctor collaboration
I have finally landed a job in Denver with a 15 member critical care group that oversees care at three hospitals, covering about 120 critical care beds. That's a relief, and now I can continue on with my plans to write a couple papers, maybe to be published or maybe not. I submitted a draft of a paper on nurse-doctor collaboration in the hospital this month to a lawyer I'm working with at the University of Pennsylvania that essentially states that it's better for patient care and it's cost effective to have better collaboration between nurses and doctors ( a kid might say, "Well doy!") Since doctors and nurses come from different backgrounds it may be helpful to have some training together in medical and nursing schools. This might include having medical students and residents shadow nurses in hospitals and vice versa. Each could learn the stresses and duties of the other, allowing for better understanding of each other's roles, and perhaps breaking some of the barriers to communication that exist at varying levels of care.
The problem is that there would still have to be a decision-making hierarchy. The empowerment of nursing has stressed the traditional hierarchy of the hospital in that physicians have traditionally held decision making responsibility while also being held predominantly responsible if something goes wrong. The call for cross training in school has been from nurses since the risk for distress in interactions is usually born by nurses. Doctors can be assholes at times. Although I believe that more cross training may actually limit some of the stress felt by both parties it seems that our biggest problem in the profession is narcissism predominantly from the physicians side, less often within the nursing profession. Many in the hospital get their undies in a bundle because they aren't getting enough attention and praise. I'm guilty of this like everyone else. Maybe we would be better off if we could somehow send a message to doctors in training that we often bear eventual responsibility for the care of a patient, be it positive or negative, but that we work in a complex setting that requires the input from not only nurses but also pharmacists, respiratory therapists, medical assistants, nutritionists and effective administrators and an array of others that can make or break a system of delivery. Some humility seems in order. Physicians are successful, or not, as a consequence of the huge and complicated network of human interaction that makes up a hospital. The reputation of the Mayo Clinic was partially an outcome of two dedicated and inquisitive doctors, Charles and William Mayo, but it survived into the future because of Dr. Henry Plummer, who set up the administrative infrastructure at the Clinic that is second to none, the Sisters of St. Mary nuns who collaborated with the Mayo brothers to develop a deep system of nursing and the people of Rochester, Minnesota who helped the Mayo brothers establish there rather than somewhere else, supplying help with making hotels into hospitals and acting as host for this world renowned institution. The Mayo Brothers would not be the icons we know without the infrastructure that Dr. Plummer and the people of Rochester created.
As for nurses, these are generally the most kind and compassionate of the medical professionals that directly impact patients. They care for the comfort of a patient with such dedication and this is often out of a doctor's emotional range and ability to regulate time given the pull of many patients as structured expectations would have it. Nurses also gather personal information about patients that no doctor could gain since they are with patients and their families more during a hospital day than any other member of the hospital team. But a flaw in the nursing literature and one that I have noticed by practicing with nurses is that there is a desire for control and decision making that may not be institutionally warranted. It would take a social change to allow more control and responsibility to be given to nurses, and this would also require that nurses accept more responsibility for negative outcomes. At the University of Pennsylvania less than 10% of law suits name a nurse in addition to the doctors involved. It is even more of a rarity that nurses are solely named in law suits. If nurses want more decision making responsibility they would have to be willing to help restructure the decision making hierarchy in the hospital and accept the responsibility of negative outcomes due to that decision making. Not out of the question, but I think it would limit their ability to be the nurturing arm of care in the hospital, maybe I'm too paternalistic here. The evolution of nurse practitioners may prove me wrong. This seems to be a work in progress.
If I were king of the hospital I would suggest that doctors take a little more time to be genuinely more kind to their nursing colleague and to take advantage of the wealth of personal knowledge that the nurse may know about the patient that we are unable to obtain. Information that may be helpful in their care. To nurses, I would have to stress that in today's society doctors have eventual responsibility for the outcome of the patient so in cases of disagreement there must remain, for the time being, deferral to the treatment plan endorsed by the doctor. In the end some of this lack of understanding between the two groups, doctors and nurses, shadowing each other in training may allow for better understanding of each other's role in patient care and a chance for discussion and exchange of ideas that does not currently exist.
These suggestions are made with humility and a desire not be thought of as a know-it-all but as someone who cares a lot about how patients get treated in a hospital. Don't we all.
The problem is that there would still have to be a decision-making hierarchy. The empowerment of nursing has stressed the traditional hierarchy of the hospital in that physicians have traditionally held decision making responsibility while also being held predominantly responsible if something goes wrong. The call for cross training in school has been from nurses since the risk for distress in interactions is usually born by nurses. Doctors can be assholes at times. Although I believe that more cross training may actually limit some of the stress felt by both parties it seems that our biggest problem in the profession is narcissism predominantly from the physicians side, less often within the nursing profession. Many in the hospital get their undies in a bundle because they aren't getting enough attention and praise. I'm guilty of this like everyone else. Maybe we would be better off if we could somehow send a message to doctors in training that we often bear eventual responsibility for the care of a patient, be it positive or negative, but that we work in a complex setting that requires the input from not only nurses but also pharmacists, respiratory therapists, medical assistants, nutritionists and effective administrators and an array of others that can make or break a system of delivery. Some humility seems in order. Physicians are successful, or not, as a consequence of the huge and complicated network of human interaction that makes up a hospital. The reputation of the Mayo Clinic was partially an outcome of two dedicated and inquisitive doctors, Charles and William Mayo, but it survived into the future because of Dr. Henry Plummer, who set up the administrative infrastructure at the Clinic that is second to none, the Sisters of St. Mary nuns who collaborated with the Mayo brothers to develop a deep system of nursing and the people of Rochester, Minnesota who helped the Mayo brothers establish there rather than somewhere else, supplying help with making hotels into hospitals and acting as host for this world renowned institution. The Mayo Brothers would not be the icons we know without the infrastructure that Dr. Plummer and the people of Rochester created.
As for nurses, these are generally the most kind and compassionate of the medical professionals that directly impact patients. They care for the comfort of a patient with such dedication and this is often out of a doctor's emotional range and ability to regulate time given the pull of many patients as structured expectations would have it. Nurses also gather personal information about patients that no doctor could gain since they are with patients and their families more during a hospital day than any other member of the hospital team. But a flaw in the nursing literature and one that I have noticed by practicing with nurses is that there is a desire for control and decision making that may not be institutionally warranted. It would take a social change to allow more control and responsibility to be given to nurses, and this would also require that nurses accept more responsibility for negative outcomes. At the University of Pennsylvania less than 10% of law suits name a nurse in addition to the doctors involved. It is even more of a rarity that nurses are solely named in law suits. If nurses want more decision making responsibility they would have to be willing to help restructure the decision making hierarchy in the hospital and accept the responsibility of negative outcomes due to that decision making. Not out of the question, but I think it would limit their ability to be the nurturing arm of care in the hospital, maybe I'm too paternalistic here. The evolution of nurse practitioners may prove me wrong. This seems to be a work in progress.
If I were king of the hospital I would suggest that doctors take a little more time to be genuinely more kind to their nursing colleague and to take advantage of the wealth of personal knowledge that the nurse may know about the patient that we are unable to obtain. Information that may be helpful in their care. To nurses, I would have to stress that in today's society doctors have eventual responsibility for the outcome of the patient so in cases of disagreement there must remain, for the time being, deferral to the treatment plan endorsed by the doctor. In the end some of this lack of understanding between the two groups, doctors and nurses, shadowing each other in training may allow for better understanding of each other's role in patient care and a chance for discussion and exchange of ideas that does not currently exist.
These suggestions are made with humility and a desire not be thought of as a know-it-all but as someone who cares a lot about how patients get treated in a hospital. Don't we all.
Sunday, July 4, 2010
Fourth of July in Montana: The Shooting of Rattlesnake Jake
I found a good Fourth of July story reported by Mary Pickett in the Billings Gazette. This was a well constructed, front page, above the crease, story in this Sunday's paper describing Lewistown's 1884 Fourth of July celebration: it's first. Since they had just established a post office it considered itself a town and the town had to have a Fourth celebration. The story was told by a 90 year old retired history teacher, Margaret Seilstad. Her father had been a twelve year old kid in Lewistown, MT in 1884 and she gathered the story from him and his friends.
That 4th of July day residents of Lewistown planned a parade, including a local resident Bob Jackson dressed as Uncle Sam, horse races, and a dance in the evening. But Granville Stuart, a historic Montana figure, who ranched in the area, conveyed concern about the celebration since he knew that horse thieves and cattle rustlers were in the area, thinking that they may steal livestock while the ranchers were in town. The townspeople wrote him off and the show went on. Indeed, by Granville Stuart's prediction, a particularly nasty pair of thieves came to the celebration that day, Charles Fallon and Charles Owen, or Rattlesnake Jake, as Owen was known. He had shifty eyes, "like a snake".
Bob Jackson, Uncle Sam, had probably been drinking and got into an argument with another local resident at the horse races but, as it was reported, a fist fight did NOT break out. Jackson was Indian and French (Metis, or mixed native and European race). Fallen and Rattlesnake Jake were drunk and approached Jackson after the disagreement that did not end up in a fist fight. Jake didn't like Indians so he hit Jackson, Uncle Sam, in the face with his pistol. Fallen and Jake then mounted their horses and left. After Fallon and Rattlesnake Jake left the races local residents converged on Main St. and stocked up on rifles at the T.C. Powers and Brothers Store because...because why not? There was something brewing.
After the altercation at the races Fallon and Rattlesnake Jake went into Crowley's and Kemp's Saloon for a few drinks, apparently already drunk and in a foul mood according to Margaret Seilstad. Jake spotted another Metis member of the local community, Doney, and shot at him but missed. Doney drew his pistol and hit Jake in the shooting finger. Jake took his pistol in the opposite hand and returned fire. After Rattlesnake Jake returned fire the angered townspeople, with their recently acquired rifles, opened fire on Fallon and Jake. Although it's not clear exactly how the gunfight progressed one version has a wounded Rattlesnake Jake riding out of town trying to escape only to notice Fallon kneeling in the street "making his last stand", said Seilstad. A loyal Jake stayed with his friend and died, riddled with "five or nine bullets", the number and any other circumstances were not perfectly clear. Both men were wearing multiple coats, in July, which apparently made it harder to kill them.
Margaret Seilstad told the Gazette that as soon as the shooting started her father went back to his tent with a bullwhacker, the driver of a team of oxen, "to get more guns." The bullwhacker was eventually killed by a shot to the head, by Rattlesnake Jake.
Before the dance started that night citizens convened a coroner's inquest and decided that the residents killed Fallon and Jake in self defense, then they danced. Although it was impossible which of the many bullet shots actually killed each man, "half the town claimed firing the fatal shots."
The bodies of Fallon and Rattlesnake Jake were stored in an ice house and the next day were displayed against a wall in town. Fallen and Jake were initially buried on Hospital Hill, where the first hospital of Lewistown existed, "but it's now the location of the Fountain Terrace condos." The man who owned the land at the time objected to their initial burial site so the bodies of Fallon and Jake were dug up, lassoed, and dragged around town, eventually to be buried near a coulee outside of town. Margaret Seilstad's father followed the body on his horse and saw bits of hair and skin from the decomposing bodies snagged on brush. According to Seilstad, "he nearly lost his lunch".
There's a skull on display in Lewistown that is thought to be from Rattlesnake Jake, but a University of Montana graduate student specializing in forensics has argued that the displayed skull is probably from a much younger man with at least some African ancestry, not Jake. Another subtle fact remains as well. It seems that Jake was shot in the head with a buffalo rifle and there was no evidence of bullet trauma in the skull thought to be Jake's. But the skull is still on display as that of Rattlesnake Jake. This is the story of the first Independence Day celebration in Lewistown, MT.
There was no mention in the story of discussions between town members of the Second Amendment right to bear arms. Not in this town. There didn't seem to be disagreement. Happy Fourth of July.
Wednesday, June 30, 2010
You can find it in the Target parking lot
I'm in Denver again interviewing for a job at one of Denver's trauma centers and doing more work at National Jewish. I'm trying to study 140-some patients who have a cavitary form of Mycobacterium avium complex lung infection, a bacteria like TB. This bacteria slowly eats away at the lungs over years and it's thought that 10-20 people in every 100,000 may have some form of this disease. Asthma occurs in about 1000 in every 100,000 people, giving you some perspective. TB occurs in about 4 in every 100,000 in the United States. I'm having computer data problems which is slowing me down but that's not what the blog is about tonight. It's about the Target parking lot.
I'm staying at the Staybridge Suites hotel, a subsidiary of Holiday Inn, having a stove, freezer and refrigerator and a couch for my comfort. It is not quite in the suburbs but it's hard to tell. Thus when I asked about a good place to eat I was directed to Applebee's, "in the Target parking lot." When I asked at the front desk if I could work out somewhere they directed me to the 24 Hour Fitness Center in the Target parking lot, and when I wanted some Pepcid for my stomach I discovered that there was a Walgreens, yes, in the Target parking lot. There is a SuperTarget in the Target parking lot, a store that not only has the red decor and array of goodies that a normal parking lot, sorry, Target has, but also this Target has a grocery store and indeed has a HUGE parking lot. Not only is there the above establishments but there is also a sporting goods store, a KFC, a Wendys, a gun shop and a strip bar. All in the Target parking lot. Just ask the front desk.
The Target parking lot is also the hottest place in Denver, in my opinion, or the world. It is bigger than a few football fields and it's newly covered in black top making it kind of a tar pit in the 96 degree sun. There were dead people in the far regions of this lot, clasping their doggy bags from Applebee's. I saw a mirage as I was crossing to the 24 Hour Fitness and before embarking to Walgreen's I left my driver's license and contact information with the front desk for fear that I might not return. I asked my friends Tim and Ginny to inform my family if someone found me dead in the Target parking lot. I have never crossed a desert, I've just gone to get some tennis balls in the Target parking lot. "Make sure you have enough water, sir!"
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