Mile 24318: Call me Erwin

Above: Graham crackers are in ready supply on the surgery floor.

"ERWIN... JOHNNY...

ALMOST."

- My attending on a fellow medical student calling me by the wrong name.

Last year, during my Internal Medicine Rotation, I found myself eating a horrible breakfast a lot of mornings when arriving at the hospital.   However, it was the most easily accessible: potato chips and cups of juice (that in truth were only 10% juice) stared right at me in the resident's lounge.  It was a terrible combination. Well, during my Anesthesia Rotation, I've gotta say that I worked on it. I'm getting more nutritious by keeping my energy levels high through Graham crackers. These wonderfully available packets (above), kept me going through taking patient histories, inserting LMAs, and following through with patients in the post-op room.  Pretty potent for a small packet, I may say.

And here I am, after a full sixteen weeks of Surgery, currently in a 2 week break before hitting the road to Columbus.  As much as I'm not going to go into Surgery, the folks at St. Anthony have really taught me an appreciation for it (with or without the graham crackers).  I'm not going to forget how the masks and scrub uniforms on the nursing staff made people look completely different than when seeing them outside of the hospital.  That perhaps led to my last nickname, Erwin, when a fellow medical student couldn't come up with my name.

Erwin... It works.

However, my last four weeks in anesthesiology were quite interesting.  Originally, my perception of a day in the specialty consisted of placing some tubes and watching the patient as they fall asleep, then waking them up, and you're pretty much done for the day.  I ended up seeing their jobs are much more important then orignally thought, making me appreciate the rotation much more.  If you think about it, just a couple ounces of anesthesia, if placed into the wrong part of the body or if dosed wrongly could put the patient in danger.

I've talked about the "art of medicine" before from my perspective, as much more of a clinical thinking concept, but the "art of medicine" in Anesthesia I saw was one of procedure.  Many of the procedures, such as spinal or nerve blocks, or even the classic intubation require a lot of muscle memory and hours of practice.  Everything they do needs to be accurate and precise, or a lot of wrong could happen.  But it doesn't.  The doctors and nurses in the anesthesia department at St. Anthony were pros at their jobs.

And with that, I'm entering back into the realm of medicine, and taking a Cardiology elective at Grant Medical Center in Columbus, OH.  This is the start of the last big road trip I will make during my medical school career, and the start of the last three rotations ever.  My journey through medical school has been amazing so far, it can only get better toward the end.

Mile 3452: Answers on the Asphalt

Above: I-95 Northbound near Brickell. An overhead shot of this strip was used in the TV series Miami Medical.

FOLLOW-UP PATIENTS
ARE MY FAVORITE.

A patient that I saw a few days ago comes in for a follow-up. He/she looked excited to see me, and that brought a smile to my face. A firm, solid handshake confirmed the camaraderie. A few weeks ago, I saw this patient in a much different state, rather sick with severe pulmonary & cardiac symptoms. Earlier in the rotation, I said to myself that I hated the idea of moving on, and well here was another case of it. The last time i saw him/her, the patient had smoked for more than 20 years and didn't want to quit. Now, he/she was just starting to quit, and I was so proud of the initiative, I had to shake his/her hand. Gosh, I was about to build a good patient-doctor relationship here, and now I have to leave. I started to get to know the patient's family, culture and more, and I would have loved to see the progress that he/she was having to reclaiming his/her own life from smoking...

I'll admit that interaction today was a good ending to a wonderful rotation in Miami. My last two weeks were spent at a more conventional medical center in the Miami area. However, our attending taught us a lot of practicality in medicine while we went through it (why we avoid certain medications, the business aspects of medicine, and just to be more confident in what we do). Now, I know how it feels to start to "want to do everything." I got hooked to treating adults too. I'll admit, that its still early in the game for me, but I hope that a week on the road can give me some answers. Driving has always been my way to think deeply about all that goes around me... There are times I think so much that I just let the dashed white lines in the road come to a blur.

Road? Yup, I'm about to start on a mini-vacation, to be myself for a week (not a medical student), think on the road, and get ready for 12 weeks of Internal Medicine which will take place at Westlake Community Hospital near Chicago. Throughout my trip, I'll be seeing some time at campus I've been at (the University of Illinois and Indiana University), meeting a few folks that helped me to get where I am today, and exploring the world in ways that I haven't been before. It's going to be exciting. However, as much as I love to travel, I miss Chicago. It's my town, Chicago is.

Thank you Miami for a wonderful experience. May the travels begin.

Holes in the Net

Above: The hustle and bustle of Interstate 75/85 in Atlanta, aka the "Downtown Connector." Courtesy Wikipedia.

"ATLANTA CAN'T LIVE
WITHOUT GRADY."
From the Grady Health System main page.

Although health care is a quintessential part of society today, the 2008-09 recession has shown that money could still be more powerful. One example: Grady Memorial Hospital of Atlanta was about to be closed in 2008 after gathering $53 million deficit, produced due to the hospital's dedication to taking care of those disadvantaged for health care in the region. However, with the following statistics showing how crucial the hospital is to the area, it would seem that closing should have not been an option:

1. It takes in 850,000 outpatients and 30,000 inpatients each year.
2. It has Georgia's only Poison Control Center.
3. It is the area's only Level 1 Trauma Center
4. It is Atlanta's main safety-net hospital.
5. Its network includes Grady Memorial Hospital and 9 more area community clinics.

In the New England Journal of Medicine, Grady Memorial Hospital was featured in an article about the holes appearing America's current safety-net.

Okay, pause for a second.

For those of you unfamiliar with the concept, a safety-net hospital is a hospital that serves a significant amount of low-income, uninsured, and disadvantaged populations. One thing that really surprised me about the definition of a Safety Net, is that ownership (public or private), isn't really the factor, but other determinants, from philosophy (e.g. having an "open-door" policy for care) to usage (i.e. proportion of incoming patients with low-income or proportion of people who utilize medicare). Most of these hospitals are eligible for what they call Disproportionate Share Hospital (DSH) payments from the government, which aid the hospitals for the costs of providing uncompensated care to those uninsured or under insured.

Whew.

Fortunately, with private donations and grants, the hospital was able to stay for the most part, open. The dialysis clinic at Grady was forced to close. Grady has done much for its patients to assign them to temporarily set them up with other clinics and to help ease transitions for those patients struggling. Although the damage to the hospital itself was minimized, there were patients that were still critically affected by the situation.

Closer to my neck of the woods, the main Safety Net Hospital of Chicago, John H. Stroger, Jr. Hospital of Cook County, is a refuge for those without health insurance benefits. According to a September MSNBC story, these disadvantaged patients are very happy to have some place to go. However, recent health care reform may reduce DSH payments to hospitals such as Grady and Stroger, potentially weakening important links in our health care system, leading to reduced coverage and maybe closure for some institutions. We've seen already how financially tight things are at Grady, for all I know there could be another handful of hospitals that are teeter-tottering in the same financial situation.

To me, the idea of losing funding for these hospitals could be disastrous. Personally, I think that its dangerous to cut funding from these hospitals, as health care for more than the low income could be affected. One hypothetical situation that I thought of is if these high capacity hospitals are closed, where else will these people go? Potentially to other hospitals that are not prepared for the added patients, stressing the rest of our health network in America. A unseen domino effect might be on the horizon.

I personally think that there are other options that are not being looked over, such as tort reform (e.g. protecting doctors from suits, so we can work more efficiently without having to worry about our backs) and many inconsistencies and inefficient ways that medicare and medicaid are being provided. Sometimes I think that the government is attempting to do so much to health care right now that if something goes wrong, we won't be able to figure out what made it go wrong, due to the extreme complexity of our health care system.

Like I said a couple of months ago: I'm all for reforming the system, but we need to be careful and think about all the potential consequences of our decisions in the long term. It concerns me that things that may appear to be good for us now might not be good for the next generation.

Sources:
1. Forum on Displaced Grady Dialysis Patients Held. Atlanta Progressive news. December 7, 2009.
2. The Grady Health System main page.
3. Redlener, I. and Grant R. America's Safety Net and Health Care Reform - What Lies Ahead? The New England Journal of Medicine. December 3, 2009: 2201-2204.
4. Will safety net hospitals survive health reform? MSNBC / AP. September 8, 2009.
5. What is a safety net hospital? National Association of Public Hospitals and Health Systems.