Scutmonkey Chronicles

Commentary on healthcare in general, life as a medical student, and issues of concern thereof. Readers warmly encouraged to contribute their "best" and "worst" experiences with the healthcare system (who knows, some budding young doctor might learn something from your pain...?) Submit via comments section, or email me at if you'd like to become a regular contributor. Welcome, and don't forget to double-glove!

Monday, November 28, 2005

Oh, the Gall

First day in surgery...three gallbladder removals and a hernia repair. Looks like I've lucked out as far as resident and attending...they're intense and demanding but very willing to teach, and also not mean. The only negative of a twelve hour day was a management level nurse who refused to show me tomorrow's OR schedule on the grounds that it "would be a HPPA violation." Oh well, one miserable curr does not a day ruin.

After the initial panic over getting scrubbed and in position without contaminating everything in the room and/or making a scene, I was pleasantly surprised to find that things in the OR follow a kind of rhythm, and that once you pick up on it, time kind of flies. My involvement today was limited to holding retractors, cutting stitches, and applying staples--not very highspeed--but more than I thought they'd let me do. And pretty cool, even for a person who has not once lick of desire to become a surgeon!

I spent a lot of the day watching the nurses get the tools the surgeons called for and figuring out what those tools are for. There are about six million different kinds of clamps and scissors, all of which are named for long-dead founding fathers of surgery. So although none of the names are self-evident, all the tools have a specific place and purpose. A purpose that I better figure out pretty damned fast.

Retractors are what the people assisting the surgeon use to hold open the incision and surgical field. They are sort of a curved, stainless steel cross between a jai-lai stick and a spatula. Holding retraction is a med student's bread and butter, and can get a little tedious, being that the holder has to apply a good amount of force while standing in an awkward posture. Following closely along with what the surgeon is doing and trying to anticipate the next move makes the task a little less tedious, but it's still very possible for a person's hands to go numb and their mind to follow suit.

Another big med student job is cutting the ends of sutures after they have been placed and tied by the surgeon. This is sort of like being the guy in the orchestra who hits the kettle drum once, maybe two or three times on a good day, during a're involvement is limited, but if you lose track of time and are not ready at the right moment, it's gonna be noticed. My particular surgeon likes to do eight "throws" on every deep knot and four on the shallow ones. This requires me to count the number of times his hands cross and be ready with the scissors at the right time.

Tomorrow morning will be my first experience dealing with non-anesthetized surgical patients, which should be interesting. One poor fellow went in for a gallbladder removal and is going to find out that we think he also has cancer. I've never had to break that kind of news yet.

Thursday, November 24, 2005

Katrina Relief Part Two: Moving Comments and Appeal for Help From My Colleague Nurse Michele Logan

Hope everyone had a Happy Thanksgiving. This year, I am extra thankful for all the blessings in my life that I take for granted sometimes. Before you read this, I want to say thanks for taking the time to do so. This letter is LONG. But, this is an issue that is so deeply wedged into my heart right now, it hurts. I asked my husband to pass this to some of his friends, along with his weekly football pool rant. I appreciate your time.

I am hoping to enlist some of you in an effort to make the holiday season a bit brighter for those people on the Gulf Coast affected by the hurricanes.

Recently, I had the privilege of spending two separate weeks in Vidalia, Louisiana, at a volunteer clinic for evacuees of the two hurricanes that struck the Gulf Coast region. Vidalia is a poor little town on the Mississippi River. The whole place probably spans 10 miles. This little town, however, took on more than 2500 evacuees. They sheltered them in their churches, their "hotels" or their homes. They sponsor them, they do for them, and they love them. Ask why they are so invested in helping people from a region almost 200 miles away, they look at you as if you are simple, and say "There but for the grace of God..."

The photos you see above were taken by me and some of my colleagues when we traveled down to the Gulf region. They are not from a magazine; I saw this with my own eyes. It was hard to believe that we were in our own country. We said to each other that this must be what it looks like after countries are bombed. The three “D” words, destroyed, decimate, devastated, were all that came to mind as we drove through New Orleans and Mississippi.

In New Orleans, wind had torn places apart, power lines hung all over the streets, and interior furnishings line the curbs of block after block. The stench in the air is indescribable. Yet, incredibly, we found families living in their homes in the midst of this. Why? Because they are so poor, they had nowhere to go.

In Mississippi, and along the lake in Louisiana, all we saw were piles of debris that had been homes. Boats and cars were in trees. Telephone poles leaned or had been sheared off from the wind. There was no power or water in most of these places. In Waveland, Ms, there were very few structures standing. The whole town seemed to be existing in a Wal-Mart parking lot. They were hit by a 37 foot wave.

Remains of Lakefront House in Slidell, Louisiana

I want to tell you a story related to me by one of our patients. She was a 58 year old woman who has worked as a janitor in the New Orleans School District. She earns $6.52 per hour! She told me she had refused to leave her home as the hurricane approached because she feared looting. She said she had a new refrigerator in her kitchen, a TV almost 2 years old, and a 1999 vehicle. She feared losing these items to looters.

I'm thinking to myself "You stayed for your refrigerator??!” Then I realized, I can never understand her thinking, because I am lucky. In my mind, so what? I will get my homeowners insurance to cover this, and go to Sears tomorrow and get a new refrigerator. When you make 6.52/hour, you don't qualify for many credit cards. So, I asked a question and learned how many years it had taken her to save her money (eight she said) for those three items. That's why she stayed. She eventually had to leave. Her home was damaged, her belongings were looted, and she has no job to return to; no way to replace these possessions that she strove for.

Health issues will become a rising crisis. In the clinic, we saw folks who had not taken blood pressure or diabetic medicines for more than 6 weeks. They had no supplies with them. They had no medicines or money to fill the prescriptions we wrote. One of the major battles we fought with FEMA was in regards to paying the pharmacies for the meds they dispensed.

Most were showing signs of depression and post traumatic stress disorder. We heard stories from those who had been in the water for days, trying to rescue others.

We heard from a woman who had been in the Superdome, and described terror greater than anything we knew of from CNN. We heard from mothers who had given their babies urine to drink, to try to keep them from being dehydrated. Yes, that's right, URINE!

We spoke to a man who had left his aunt's body tied to a post in their attic in New Orleans so he could get back for her, and set out in the waters with his mother and sister to get to the Superdome. Their mom died on the way, and when they were picked up, they discovered a snake in her backpack. She died of a snake bite. He had no idea where his sister was, because they had been separated.

We talked to people from Mississippi who described a wall of water 16 feet high. We heard from a man who had to jump from his bedroom window, with his wife, onto a gas tank from a boat and float to safety.

We treated a woman who was getting her tetanus shot on October 27th, so she could get back to Bay St. Louis the next day, and retrieve her mother’s body. Mom had finally been found, almost two months later.

I listened to a tall Cajun man, in overalls, with a grizzly beard cry as he explained how hard it was to leave his dogs behind. He had used a stolen boat to rescue 11 different people from their rooftops and attics. He described how they had hidden from police who wanted their boat. Then he had walked 6 miles, through the muddy waters to get to the overpass and wait for a bus. He told me he might write a book about it.


Katrina devastated 23,000 acres and destroyed nearly 284,000 homes. The death toll in Louisiana alone is 1,053. That does not count Mississippi, Arkansas and Florida; all damaged by this storm system also. Schools are gone. Hospitals are gone. Fewer than 15% of the doctors in New Orleans are back at work. 71,000 businesses have been shut down by Katrina, 10,000 more by Rita. I am only giving you details about Louisiana, not the other regions.

The residents are still scattered around, waiting for assistance. They are not in their homes, or in their town, or near friends and sometimes family. Their children are in new schools. If they remain in the region, like in Mississippi, they are living in tents and eating at makeshift shelters. If they were moved to towns like Vidalia, they may be in motel rooms or if lucky, a new FEMA trailer. FEMA announced this week they will cease paying for hotel rooms as of January 7, 2006.

Meanwhile, these displaced, disenfranchised citizens have no money, no health care, and no jobs. Some have none of their essential paperwork, because it was destroyed. They left their cars back home; they left their medicine and health records at home. Many are still searching for members of their families. They must rely on the generosity of strangers to survive, while trying to maintain some semblance of dignity.

Suffice to say, the "relief" agencies like Red Cross and FEMA are largely ineffective in this effort. Bureaucracy is tying up relief. Congress allotted nearly $62.3 billion dollars to FEMA. More than $37.5 billion is still sitting in FEMA's account waiting for a purpose. Of the nearly $25 billion assigned to projects, only $6.2 billion in checks have been cashed. Because of this, Congress is considering taking back some of the money.

Meanwhile, these folks live in dirty hotel rooms, or 6 families to a home, and rely on charity for medical care, medicine and food.

I am not making up these numbers. They are documented in a Time magazine article this week.

OK, you get it. ...these folks need help. I have been told that I can’t save the whole world, so, I chose my spot. The holidays are coming, and going through them in this fashion is heartbreaking. There are 22 families that have been given FEMA trailers in Vidalia, LA. We are trying to collect money or WAL-MART gift cards for the families that have been relocated. It is so hard to imagine a holiday with no meal, or kids on Christmas morning in a ratty hotel room or a FEMA trailer, miles from home, with no presents to open, and having no choice but to rely on the generosity of strangers around you. Our goal is to present each of the 22 families with a gift card from Wal-Mart in the amount of $100.00 or more, if we can raise that.


Please find a way to help these fellow citizens of our own country. The fact that they were so economically challenged and impoverished to begin with is what is making this disaster so difficult to deal with. Look at these photos I inserted. Multiply what you see by everywhere you turn.

You can send a donation, or a purchased gift card. A Wal-Mart card in any denomination will help. In the south, you can get everything - food, clothing, prescriptions - at Wal-Mart. We are dealing through the First Baptist Church in Vidalia, and the nurse who operated the clinic I worked in, Grace Woods. We are planning on sending our gift packages on December 12th. Please... join me in trying to make these folks lives just a little better. They have been through living hell, and they need to know that the rest of us care. They deserve it. They need our help and our prayers. They need us to be engaged.

Look at some of these websites for other organizations to get involved with: - Their organizer was just awarded the RFK Human Rights award. They deal with communities in need, and are working on rebuilding the N.O. neighborhoods. - Grass roots group who went into the Gulf region and asked "what can we do" Doing lots of manual labor in Biloxi, MS. (these are a bunch of old hippies traveling in painted up school buses. I met them in Waveland, MS, manning a relief center where folks can eat, get medical attention, and chill out) - Houston/Galveston area chapter assisting those who took Katrina victims into their homes

First Baptist Church - 100 SOUTH HICKORY STREET, VIDALIA LA 71373

I know this is long. Thank you again for entertaining my thoughts. Please, pass this on to others. One person can make a difference.

Each time a man stands up for an ideal, or acts to improve the lot of others, or strikes out against injustice, he sends forth a tiny ripple of hope, and crossing each other from a million different centers of energy and daring those ripples build a current which can sweep down the mightiest walls of oppression and resistance. Robert F. Kennedy, 1966

Michele Logan
102 Mockingbird Ct
Swedesboro, NJ 08085

Wednesday, November 23, 2005

Next on the Rotation Schedule: Cut and Paste

Now leaving the relative ease and safety of psych and radiology and moving on to surgery, the specialty where the crazy people have the knives. Also passing sort of a landmark, having completed six months of rotations with five more to go to finish third year. (Done: two months of family med, peds, ob/gyn, psych, and radiology. Yet to come: general surgery, specialty surgery, internal med, cardiology, and neurology.)

Although I have no desire (that I know of) to become a surgeon, I am more excited to embark on this rotation that I would have expected. This is probably due mostly to a really good week of "surgery prep" class put on by the head of my school's surgery department. If one were to believe the generalizations about surgeon personalities (nasty, brutish, and short-tempered, to steal a phrase from the Brits)this man is unusual in his enthusiasm and warmth in passing on the finer points of the cutting arts to med students. Hopefully there are more out there like him, particularly in the ORs of the hospital where I will be going.

On the other hand, a student in the fourth year class who has been a reliable source of information for me since I began med school said of interactions with surgical attendings, the question is not IF they will scream at you, but how often and how loud. Well, hey, it's only a month. Not that I like being screamed at, but if getting hollered at is the price of learning the stuff and getting through the month, I'm sure I'll live through it.

Saturday, November 19, 2005

My Experience with Katrina Relief: Faith, Hope, and Bureaucratis Interruptus

During the last two weeks of September, I had the privilege of being part of a team that opened and ran a crisis medical clinic for hurricane evacuees. The clinic was located in Concordia Parish, Louisiana, which had become temporary home to about twelve thousand displaced folks from Southern Louisiana and Mississippi.

It was one of those experiences that really jars a person's consciousness and forces a re-prioritizing of what is important in life. I could (and will, a little bit later on) go into detail about negative aspects of the experience, such as dealing with red tape from FEMA and the public health structure. Before discussing that, though, I want to emphasize that more than anything else, I was impressed with and inspired by the endurance and spirit of the people we took care of. I cannot really imagine myself keeping that of an good attitude under those circumstances. Can you?

Had dinner last Sunday night with an extended crew of docs and nurses who took over the clinic after my team left. What an incredible group of people! Over corn bread, pulled pork, and red beans and rice we shared our experiences and made tentative plans to provide more support if we can. For me personally, that meeting might end up with me following some of these folks into their residency program.

Besides eating, a major purpose of the gathering was getting together a nomination for the Florence Nightingale Award for our local host in Concordia, an exceptionally committed and brave nurse named Grace Woods. In addition to securing space for the clinic and getting people to donate the various furnishings it required, Grace put together the teams of medical volunteers from around the country, got us housed, fed, and trucked around town, and put out fires on a daily basis that would have stopped less dedicated people cold in their tracks.

It would be impossible to tell you in one blog entry all the reasons why Grace deserves this award, but I will sum it up by telling you that when she heard that she'd been nominated, her reaction was to ask why. We ended up with upwards of twenty pages of testimonials to accompany her nomination. I know there are probably a lot of deserving candidates out there, but I sure hope Grace wins.

Besides being impressed by Grace and inspired by the people we had the privilege of taking care of, experiences differed somewhat among the three teams who worked the clinic. However, two issues really came to light as commonalities. The first was the need to be creative under what could only be described as frontier conditions. When slide fixative was not available, hair spray got the job done. When lighting in the clinic was not adequate, backpacker-style headlamps were pressed into service.

(Now, for comic relief, imagine a scrub-clad med student, can of Aqua Net in each hand, getting ready to declare a medical emergency to jump a long supermarket line, stopping herself just in time to realize how that might seem to the other customers...)

The second and less comical commonality was unanimous frustration with red-tape loving bureaucrats. I am NOT talking about the boots-on-the-ground government Joes rowing around flooded streets, searching houses. This criticism is targeted at the mid and higher level wonks who not only did not do their own jobs, but seemed to relish stopping other people from doing theirs.

We came to call this phenomenon "Bureacratis Interruptus." Although it eventually was applied to all situations involving red tape, the name was originally given to one very deserving mid-level FEMA official sent from Washington to "help" in our region. Although I did not witness it personally, "B.I." became famous for telling a roomful of meeting participants he was calling his boss for an answer to a question they had posed (and posed for the third or fourth time...), then dialing his own voicemail and carrying on a pretend conversation. Unfortunately, what this gentleman did not realize was that the volume on his phone was set to such a volume that everybody within thirty feet figured out what he was doing. BUSTED!

The most heinous of the FEMA gaffs that I can attest to personally is the continued failure to honor an agreement made with local pharmacies to reimburse them for the gratis filling of prescriptions written at our clinic. In effect, this put the pharmacies in large amounts of interest-bearing debt. For WalMart and CVS, this may not have been such a huge deal. For the Mom and Pop pharmacy outfit in town that gave away $32,000 in free medicine during the seven weeks our clinic operated, the burden was huge. (As a side note, WalMart and CVS stopped honoring the deal weeks before the Mom and Pop guys did.) At any rate, this failure to pay back pharmacies was a major factor in the decision by the last team to man the clinic to cease operation and transfer care of our population to another site.

Although FEMA was the most obvious and obnoxious offender, another serious "B.I." contender was a federal and state public health structure that threw up unending obstacles re: honoring out of state licenses and issuance of badly needed vaccines. Way to encourage altruism, guys! Lower on the offender list would be the well-intentioned but out of touch leadership of the Red Cross.

(to be continued...)

Tuesday, November 15, 2005

Healthcare comments from "Litagatrix"

Scutmonkey Chronicles is grateful for the following healthcare comments sent by "Litagatrix", who describes some interesting experiences, both good and bad, with medicine:

Worst Healthcare Experience: A while back I had to have my thyroid removed when doctors discovered possibily cancerous nodules forming in it. The good news, no cancer. The bad news, for over 8 months my thyroid levels were out of whack.

Symptoms of low thyroid hormone include fatigue, depression, memory loss, feeling cold. I had all those. I was in a very high pressure job and for 8 months I was having a terrible time functioning. I would forget what I was saying mid-sentence. I would be in the midst of a task and forget what I was doing and why. I would come home from work and either go to sleep, or break down crying.

This behavior was completely abnormal for me. When I went to my ENT who had performed the surgery, she suggested perhaps I needed a psych consult or counselling--because (without checking my thyroid hormone levels) she was sure I couldn't need a higher dose of hormones. I went to the family physician at our local clinic. After going in multiple times, he finally agreed to test my hormone levels, while all the while telling me I shouldn't be blaming my personal failings on hormone levels.
I was so angry and so frustrated.

Finally the test results came back and that doctor called me up to sheepishly admit that my TSH was 4 times the normal level---12.3 as compared to 3.1. Finally! Vindication! The moral of this story is that although there are a lot of hypochrondriacs out there, good doctors listen to their patients instead of discounting their symptoms and their assessments.

Doctors have the benefit of incredible training and experience, but a patient and his or her family are in the best position to explain "what's normal" and "what's abnormal" for that patient. Having hypothyroidism (?) for 8 months nearly wrecked my career, and could have been easily avoided had my doctors listened to my concerns and symptoms, and ordered a relatively simple test.

Best Healthcare Experience: When my son was 8 weeks old he had developed a severe case of jaudice. We took him to our family pediatrician who in turn sent us to the local hospital's pediatric clinic. There we met with an exceptional doctor.

Not only did this doctor truly love children and listen to our concerns, but when the initial tests came back indicating that my son had exceptionally high bilirubin counts, he acted immediately to follow-up with other tests to determine the problem. What made this experience so wonderful was this doctor's commitment to his patients.

When we received the initial news, he gave us his home phone number and told us to call him if we had questions later on about the tests or the eventual diagnosis. He called me at home in the evening when the follow-up test results came back, and offered to call my husband (who was travelling at the time) to explain the results to him. We never called him at home, and wouldn't have done so in any case, except in an extreme emergency. But it was so comforting to know that he cared enough to make himself that available. As a professional myself, I now give that same courtesy to my clients.

Healthcare Comments from "Grasshoppah"

Submitted by my good friend Grasshoppah, an engineer with some thought-provoking insights on the practice of medicine:

1) Doctors need to ask patients more about their diet and daily routine. If they are claiming that they are tired is it because they work three jobs? If they are eating fastfood every meal; yeah their cholestrol will be sky high. Before medicating the symptom, try to figure out if it is a product of their chosen lifestyle.

2) Medications are first tried on animals then a select few humans, passed by FDA & finally released to GP. Those first few humans that they medications are tried on; how is their lifestyle documented? For instance; GP drinks caffeine. I would suspect that those first few human subjects drink caffeine. DO you think that maybe the medication works differently on those that do not drink caffeine? Women?

3) Also, have been told that once I am pregnant I will have to take injectible Fragmin every day to thin my blood (I have an anti-cardiolipid sp?; my blood coagulates quicker than others). Fragmin has been used for many years...they tell me that they have been using it on pregnant women for a few years...where are the studies saying that it is okay to use on pregnant women?