Perspective in Medicine and Motherhood

Slippery Slope...

2011-12-17T18:47:00.001-08:00

Seen it all now...did a vag exam on a lady (STD check) and she had a tattoo in her inner thigh that read "slippery when wet" REALLY??? That's almost as bad as what I saw in Residency - a lady with genital warts and the tattoo on her thigh reading "phat kat" with a pic of a cat...smdh

Nasal FB

2011-11-25T02:17:00.000-08:00

So I a sitting in the Living Room talking to my husband when my 3 year old came up to me and said so calmly and matter of factly "Mommy, can you help me get the bead out my nose?" I slowly turn my head to her in absolute disbelief and say "What?" And she again just as calmly says "Can you get the bead out my nose?" My husband and I look at eachother. I tell her to come close. In her right nostril is a bead. I try to press it out from posteriorly with no success. I tell my husban to get something - anything to help me get it out. She starts to fuss and cry. I tell her to stay calm and I find something similar to tweezers and, like magic, I get it out. I comfort her and am glad that I avoided an ER visit. Doctor skills or mommy skills? Maybe both.

Oh, and I started a new blog. I just found out last week that I am pregnant! So I have a blog completely dedicated to that journey at http://secondpeanutexpecting.blogspot.com/.

Doctor Mommy

2010-12-12T06:21:00.000-08:00

My 2 y/o has asthma. One day, she was wheezing pretty bad. I told her "Sweetheart, you are wheezing. Let's give you your breathing medicine." Then I gave her a breathing treatment via her nebulizer. After her treatment I listened to her lungs, having her breath deeply. Then I said, "Wow, your lungs sound soooo much better!" with great enthusiasm. She looked at me and said, "Thanks Doctor Mommy!"

Grown-up Juice

2010-11-14T16:44:00.001-08:00

I love being a Mom! And my dear daughter says and does the cutest things. Aside from asking to trick or treat a few times a week because she had such a blast Halloween weekend, she's a comedian! The other day, we were eating dinner and I had a glass of wine. She said, "Mommy, can I have some?" I said, "No baby, drink your apple juice." She said, "But mommy, I want your apple juice!" I said, "Oh, no honey, this isn't apple juice, it's....grown up juice!" She said. "Oh. There's grown ups in there???" I just LOVE my lil' diva.

Perscription Fraud

2010-01-19T11:30:00.000-08:00

Okay, so I work in a very small town. It's just me, the Receptionist and the RN most times. We have funding for a medical assistant. Had a great one for a few months who became really sick with her pregnancy. Then we had a new girl. Lets call her Ms. Hyper Viper. Very enthusiastic, hardworking, gets the job done type. Almost overly enthused always asking "What can I do? Can I help? Can I do anything else" type of personality. We'd joke with her about her being on speed or needing something to calm her down. It is so great to have a medical assistant to spread out the work load since we do a lot of patient assistance programs and various other programs requiring lots of documentation for funding and grants - takes a lot of stress off of our nurse.

Today the MA came in looking kinda sick - tired. I asked if she was okay and she said she was. Soon after she said she was throwing up so we had her go home.

I got a call from a pharmacy in one of our neighboring towns calling to validate a perscription that was written over the weekend. The name? Hyper Viper. It was for 2 controlled substances, one of which I NEVER perscribe, each with two refills. Had "my" signature (forged), but the wrong DEA #. I told the Pharmacist that I did not write that and not to fill it but he said it was done over the weekend (when he was not there) but he would cancel out the refills and tag her file. They faxed me a copy.

I feel so violated and betrayed. She must have practiced my signature because it was close. She no longer works here of course. I wonder if she's done this before. I wonder how many blank scripts she may have and how many pharmacies she may have gone to. I'm so upset right now.

And Today I Was A...

2009-12-17T20:42:00.000-08:00

The one thing I continue to LOVE about family medicine is the variety - you never know what you're going to get.

This afternoon, I was a Psychiatrist. I extensively counselled several people with depression - restarted meds on one lady who stopped taking them for religious reasons after explaining how depression is truly a disease, much like high blood pressure...explained the role of serotonin, and if treatments exist, I believe there is no sin in taking them especially since in her case it had worked well before. I handed another patient kleenex as she talked about her hardships. I diagnosed one with Panic Disorder after ruling out other causes of her spells.

Yesterday I was a Pediatrician. I saw rashes, ear infections, URIs, kiddo with a boil, I even got to take a GIANT wad of paper out of a 4 year old's nose!

Earlier this week, I was a Gynecologist. Pap smears, breast exams, diagnosing BV, STDs, setting up Mammograms, discussed Breast Care (which ran out of funding for the year BTW), etc. I even had a case where a 15 year old and her mom came in - the girl with dysuria and noticing blood when she wiped. The Urinalysis did not look like infection, but I explained that I'd send it for culture and treat until the culture came back and see if anything needed to be changed. I just had this feeling, so I tacked on a gonorrhea and chlamydia lab to her urine. Sadly enough, the chlamydia was positive. Had to counsel her today...

Anyhow, I still love it. Family Practice is like a box of chocolates. Each day, you never know what you're gonna get.

Dr Medicaid, when is your next appointment?

2009-11-27T05:00:00.000-08:00

So I have a patient with Diabetes which has recently become poorly controlled. She was on Glyburide / Metformin 2.5/500 BID and her blood glucose was in the mid 300s. HgA1C was almost 9. She tells me how she is drinking 6 or so sodas daily and not eating right. I advise her on healthier eating habits and have her double her pills for the next few weeks (2 in the am and 2 in the pm - I don't like for my patients to waste pills every time a dose is changed). She comes back for follow up a few weeks later. I review how she is eating and taking her meds and she has been doing as advised for the most part, however, her accucheck was 400. So I write a script for the higher dose of Glyb/Met (so she no longer has to double her previous script) and give her samples of and write a script for Januvia - another diabetic med.

No sooner is she out the door that we get a call from the pharmacist - her insurance requires prior authorization before filling the Januvia. Basically meaning I have to get permission from the insurance company before I can treat the patient with this med. So my nurse calls Medicaid and answers their 'screening questions' only to be told that they will not cover that until she has been on the glyb/met 5/1000 BID x 3 months. I am livid! They don't even include the past few weeks of her doubling her pills because it didn't show up in their system since it wasn't an official script.

So now she has to run around with blood sugars in the 300-400s for 3 months before they will pay for her med! And if she has to go in the hospital with DKA or hyperosmolar nonketotic diabetic coma, her insurance will have to pay way more for that hospitalization!

I wonder if I can set her up with an appointment for Dr. Medicaid's clinic since they can so easily dictate patient care. What is the point of having doctors if we cannot even treat the patient without permission?

My Baby Girl was sick...

2009-11-25T16:32:00.000-08:00

Well, my baby girl (20 months old) got sick. Saturday, she started coughing nonstop. Dry, but almost nonstop.

Sunday morning I noticed upper airway noise but listened with my stethescope and her lungs were clear. She was breathing kinda fast. It reminded me of when she had Croup last year. I called one of my colleagues who looked her over and thought she didn't look that bad. We gave her some Prelone syrup. Later that day she got fever 103.

Monday, she was worse. This time the wheezing was all in her lungs and she was retracting some. I was trying to give her her albuterol but she would have none of it - not enough anyway. I took her to the ER (the ER Doc on is a close friend of the fam and I worked with her during my Residency a few times) and we gave her a few updrafts (without officially checking her in and doing lab work, etc as I didn't have my new insurance card with me). She got a little better but was still wheezing some. I figured since she was on steroids, it would continue to get better. I was wrong. Oh, and she was not eating much at all.

Tuesday morning she was worse, wheezing everywhere (I could hear her across the room). Retracting some, breathing fast. Looked ill. So I paged her Pediatrician who happened to be on call. She told me to take her to get a chest Xray and bring her to the office at 10am.

When the Ped listened to her, she had her Nurse Practitioner and Student Doc listen too - her wheezing was so bad. She also had a bad ear infection. Flu and strep tests were negative. She had to go in the hospital for scheduled updrafts, IV steroids and IV fluids.

I don't know why it surprised me that she'd have to be hospitalized. It broke my heart though. They had to stick her 3xs to get a line which came out before her first meds were given, then they had to stick her 3 more times. She ended up having to get it in her foot.

She tested + for RSV, a virus that affects the lungs and in many cases just causes cold like symptoms but for an unlucky few, like young kids prone to wheezing, it can make them very ill - as it did my little girl.

We were there overnight. She was a real trooper. We're home now. She's still sick, but much better. Still on a lot of meds.

Soon as we pulled up to the house and I started getting stuff out the car, she said "Momma! Momma!" and I looked at her and said "What baby?" And she says, "French fries? French fries?" So I get back in the car and head McDonalds. How can I say no to that face?

Young Sex

2009-10-31T18:48:00.000-07:00

I also work 1/2 day a week in an adolescant / young adult clinic.

"Good morning doc" one of the college kids says to me when I walk in.

Good morning, I am Dr. Blank. What brings you here today?"

"Well, this girl I been messin with got chlamydia so I want to be checked to be sure I don't have it."

"Are you having any symptoms? Pain, discharge?"

"No. It's just that I got a girl back at home and...she even got a man at home...I just wanna make sure I aint got nothin or bringin nothin to my girl."

So I examine him, test him, counsel him on safe sex, and offer him free condoms (which he declines).

I see so many STDs in this population it is like an epidemic. It saddens, angers, and worries me all at the same time. In this case he was acting like it was no big deal at all. *sigh*

My Mental Week

2009-10-17T08:40:00.001-07:00

I called this entry My Mental Week because sometimes patients and their lives can...weigh in on me. This week I had a lot of patients who I spent a great deal of time thinking about.

In Smalltown USA, I see so many people, so many sick people that need help - with no insurance. We have a sliding fee based on income, so we welcome them. This is quite different from Residency. As a Resident, I would be quick to treat a bladder infection with levaquin and not think twice. The vast majority of patients were insured and did not have a problem getting meds. But it is crazy it is to prescribe Levaquin to someone who's husband just lost his job and is struggling to feed 3 kids. Rarely do I prescribe something that is not available on the $4 list and hope that they can get that or treat various ailments with a shot or something available at the clinic or available through a perscription drug program.

Yesterday I saw a man who suffers from chronic pain after having a GSW many years ago. He confessed that he never filled his last script (for Meloxicam and Amitriptyline) because he could not afford it ($30 something dollars). I explained that if he could go to the next town to walmart and they would both be on the $4 list but soon learned he has no way to get to town and does not have $8. So he got a toradol shot. I don't know, I wish I could do more. I then offered him the flu shot and he declined saying "Every one I knows that got the flu shot got sick!" I quickly replied that I got it and I'm not sick (hoping not to jinx myself shortly after I said it). "But you're a doctor!" I couldn't convince him. lol.

Then I saw a lady regarding rapid weight loss - 35 pounds in 7 months! and only 51 years old! She weighs less than 90 lbs and just looking at her I know she has cancer (well, I don't know, but I'm pretty sure). I took a very detailed history. She smokes heavily (lung cancer?) has problems with constipation and bloody stools (colon cancer?) and she still has her ovaries (ovarian cancer?) and has not had a breast exam or mammogram in many years (breast cancer?). She asks me if we can just do some blood work to find out what it is and see if maybe a pill can fix it. She is very pleasant, jovial, and optomistic. As I ponder with how to approach this, I tell her that whenever someone has such rapid weight loss cancer is a definite possibility and she says "Oh, I know! I know! But if it is cancer, I don't want any drastic measures done, just keep me comfortable and let me die!" I counsel her about colon screening and my concerns with her bleeding and she declines. "I don't want to go through a lot of tests! Nothing invasive" I suggest pelvic exam (declines) and a breast exam and mammogram and give her the breast care pamplet as they will pay for that. She says she will think about it. I set her up for a chest Xray which she agrees too and basic blood work. Rapid HIV screen was negative. I will see her next week to review results. I considered ordering tumor markers like CEA, etc, but our lab can't do those and they are very expensive. I don't know if the basic lab will suggest any etiology (like liver metastisis or high alk phos / bone mets) but we shall see I guess. **sigh**

Also, I saw two young girls with Chlamydia. One acted like it was no big deal and the other was so hurt perhaps by her significant other that she could barely speak. I remind them that free condoms are always available here and give them some and encourage them to take care of themselves.

And I found out one of my sweetest patients is a drug seeker. I happened to talk with the ER doc in the next town who I did my Residency with and apparently she is in there several times a month scoring pain meds for various reasons. My nurse confirmed this with two pharmacies. On one visit, she had told me specifically that the ER gave her something for nausea and not pain and I actually believed her and gave her something. She filled a script for Darvocet and Vicoden (from 2 different doctors) at the same pharmacy on the same day!! SUCKER on my head I guess. She has an apt next week and I'll have to tell her no more narcotics from me. I don't know why I am so offended. I guess I thought I was pretty good at detecting drug seekers, but my radar completely missed her. No it's not the first time a patient lied to me, but...idk.

Heartworms

2009-10-14T20:01:00.000-07:00

5 year old girl brought to clinic by grandma because of her chest hurting when she coughs. During the exam, her grandma says "she thought she had heartworms but I told her that only happens in dogs." We both giggle, then the girl says "No granny! I can't have heartworms, I am not a dog! Unless mommy is a dog...or unless daddy is a dog." Grandma says, "Well yes baby, your daddy is a dog, that's for sure!"

ADHD and E

2009-10-13T20:10:00.001-07:00

I saw a kiddo today who was diagnosed by the local mental health facility with ADHD and was sent to me for monthly perscriptions since he lives close to our clinic. At one point when talking to mom, she said "He went from making A's and B's to making D's and F's" and he quickly and enthusiastically added "And E's!!!"

Sex, Lies, and Madness!

2009-09-16T19:48:00.000-07:00

Case 1: 24 y/o female presents to clinic for lab review. She had her annual exam and pap smear last week. Very sweet girl, in a long term relationship with her boyfriend of 3 years. On birth control.

Tested positive for gonorrhea.

"I don't understand how that happened..."

Unprotected sex. Case closed.

Case 2: 16 year old female presents to clinic with nausea, vomiting, stomach virus' x 2 weeks. History positive for smoking 1ppd and occasional marijuana use.

Last menstrual period: 2 months ago.

"Do you think you could be pregnant? Did you take a pregnancy test?" I ask.

"I did a few weeks ago and i was positive, but turned negative so I figured I wasn't pregnant."

"Well it is positive today. Congratulations."

She looks at me stunned.

"Do you think you can stop smoking?"

"Yes, I want to do all I can. I don't want to have a miscarriage like last time."

A tear falls from her eyes. I hand her kleenex.

"Is everything okay?"

"Yes it will be, just a little stunned."

"Is the father still in the picture?"

"No we broke up a few weeks ago."

I proceed to counsel her and give her a script for prenatal vitamins and some recommendations for her morning sickness.

Case 3: 55 y/o male presents to clinic with pain during urination. Urinalysis is negative for urinary tract infection.

While getting the basic history, I ask if he is sexually active. He looks down and says, "I lost my wife a few years ago and was not sexually active...until a few weeks ago. I met this girl and we really clicked. I thought we'd be together for a while. We did not plan to have sex but it just happened. Since it wasn't planned, we did not use protection. We are not together anymore. Do you think I may have caught something?"

So we test him for gonorrhea and chlamydia. A few days later he returns for results - he is positive for chlamydia...and treated. "I have learned my lesson" he says. I certainly hope so.

Sex, lies and madness. Sex can be such a beautiful precious thing - but boy can it be dangerous and life altering.

As always, some details are changed to maintain confidentiality.

A New Chapter Begins...

2009-09-11T04:09:00.000-07:00

It has been almost 3 months since I completed my Residency in Family Medicine and started my new job - a small town Family Practice Physician. I absolutely love it! I work in a town with a population of about 1500 people, but services about 3000 including surrounding areas - and just 20 minutes from where I live! Staff of three at the moment, a nurse (RN), the office manager / receptionist, and...me.

I enjoy the patients - variety of ages and pathology. Ofcourse the bread and butter of medicine - Diabetes, High Blood Pressure, Heart Disease, but even the rare like a young girl with Phenylketonuria, a teeager with Von Hippel-Lindeau, and a few with Lupus, Rheumatoid Arthritis, and other ailments. The staff is absolutely great. And at the moment, I am doing clinic work only with no hospital call which has many benefits! I have a regular consistent schedule, enough time for a few activities with the church, and time to spend with my young daughter.

I am in the process of applying for hospital privileges so that I can follow a few patients in the hospital (20 minutes away but in the town where I live), but I won't have to take call. A new chapter in my life has begun.

Oh, and I passed my Family Practice Boards! Yay!

So professional wise things are going great. The family and I are preparing to move to a nicer neighborhood in the next few weeks. We closed on our first home a week and a half ago.

And my baby girl is just getting bigger and bigger! 18 months old now! Excellent speech skills and overall a very bright baby - of course I am biased. But even the daycare workers say so. She knows her body parts, even her eyebrows. She can say her name, knows her age and she is sooo loving and playful. She is my absolute joy!

My Baby Girl

2009-05-08T18:33:00.000-07:00

My lil girl is growing up so fast. It seems like just yesterday she was a tiny little thing, wiggling, sleeping, nursing, crying, etc. I can remember being up late nights to nurse her and as we lay, I'd thumb through the channels...stopping on The Cosby Show and A Different World. I didn't even know that show still aired!

Now, she is 13 months old. She just started walking a few weeks ago. She can say "Mamma, Dadda, Bah-bah (for bottle), No, Ah-ah, Dop (stop), iper (diaper)" and she can point to her nose, ears, make a 'pretty eyes' face (squints her eyes), and her fro (hair) lol.

I just love her sooooooooooooo much!

I so love clinic!

2009-05-06T16:58:00.000-07:00

So yesterday was my first day back at my family practice clinic after a month of being away for a rural rotation and I had so much fun!

First there was a lady who after we addressed her complaints, she said how she kept clearing mucous out of her throat and she demonstrated it over and over with the most wierd sound that I just cannot put into words and she kept saying "like this" and doing it over and over again for the rest of our encounter.

Then there was the guy who pulled a muscle and told me every detail except how it happened and after I asked he finally said he pulled it during sex.

Then there was one of my patients who is always trying to get me to prescribe diet pills to no availe, bless her heart. She tells me about her eating habits and exercising and adds how she already told one of my colleagues "You know, the scruffy one!" as she gestures a beard. He grows a beard every hunting season. She makes the wierdest face and says "Did he shave that yet?" I was laughing so hard. He and I are always teasing so I've got to tell him.

Then the couple. The guy has COPD and is coughing and wheezing so I gave him a steroid shot and an updraft and as he takes the updraft he leans his head back and squints his eyes pretending like he is smoking weed and getting high and his wife is like "Stop that!!" He says how when he coughs, his forehead hurts so bad and she is like "It's probably those devil horns trying to poke through"

I love my patients. LOL. Welcome back.

Rural Medicine - LOVE IT!

2009-05-06T16:44:00.000-07:00

So this past month, I had the wonderful opportunity to work in the rural community which I plan to practice in about 25 minutes from my hometown and I LOVED IT! I love the clinic! The staff, though small (only an office manager / receptionist, a nurse, and a medical assistant) was very friendly and helpful. The physicians that I worked with were nice and the people, and I enjoyed taking care of the patients. A great deal of the time is spent not just treating the patient, but helping them in all aspects. Not just prescribing the drug of choice, but checking if they had an insurance that would help cover, seeing if they qualified for a patient assistance program to help with costs, and / or trying to choose medicines that work for their illness and are on the $4 list - taking care of the whole patient, not just their ailment.

I am really excited about it.

I have turned in my paperwork for the job at this community clinic as they have physicians covering on different days, but no full time physician. The only issue now is that a different community under the same management became available and they are trying to get me to go there as that physician is leaving in July. But someone has a contract to start there in 1 year and if the place I want to go finds someone else, I may be left to find a different job altogether after only one year of work! (I have a rural obligation because my loan-sholarship for medical school paid a great portion if I agree to work in a rural area.) I am supposed to meet with him Friday and hopefully we can work something out. I fell in love with that place!

The Pharmacist from Hell

2009-01-10T17:10:00.000-08:00

Okay, maybe I am taking it a bit far. But let me tell you what happened.

The other day, when I was on call, my father asked me to call in a script for something to help dry up his cough. I told him I would when I got some down time. While I was at the hospital rounding on patients, I saw one of the patients I was on was taking Guaifenesin Long Acting (LA) 1200mg every 12 hours. Then I remembered my Dad's request. So I called in that very script for my Father. Yes, I know it is pretty much the same as Mucinex, but Mucinex comes in so many doses and types. Plus, if it is a perscription, many times insurance will help pay for it (unlike if you get it over the counter). So I called it in.

Later that night, my Dad calls me very upset. He said he went to the pharmacy (drive through) to pick up his script and at first, the lady said she did not see / could not find the order. So she went to get the pharmacist. He comes to the window and says "Oh, well that doctor must not know what she is doing! You can get this over the counter..." He gives him Mucinex 600 mg and tells him to take 2 every 12 hours. My Dad wanted to say something but my mom stopped him.

Now, sometimes my Dad can embelish a story, so when I talked to my mom, I asked her did that really happen and she said, "Well, yes, that pharmacist did say that 'that doctor must not know what she's doing!' They are not supposed to say that, are they sweetie?" "No" I replied. Kind of hurt. Quite upset.

Initially, I figured I would let it slide seeing as I am a Resident (though third year) and it's not like I have my own practice in the town or anything...yet. But the more I thought about it, the more it seemed that something should be done.

The next day, I talked with the Pharmacist at our clinic about the situation. She was quite enraged at him and said that there was nothing wrong with what I did and what he said was absolutely inappropriate and unnecessary. She urged me to talk to the Pharmacist and added that maybe he was having a bad day or something and just said something he didn't mean. And maybe, just maybe, he'd apologize.

So, I called and this is how it went after he got on the phone.

"Hello?"

"Hi, ____, this is Dr. ___ how are you?"

"Oh, I'm good and you?"

"Oh, I'm good. I just wanted to talk to you about something."

"Sure, sure, go ahead."

"Well, Saturday, I called in a script for Guaifenisin 1200mg Q..."

"...Yes, yes, I know. I took that order."

"Okay, well, I understand that when the patient came, you told him that 'That doctor must know know what she's doing, you can get this over the counter'"

"Oh, no, I was just saying that Guafenisin is the same as Mucinex and he can get it over the counter"

"Yes, I know that, but I wanted him to get a specific dose which is one reason why I called it in.that, but I also understand that you said that 'That Doctor must not know what she is doing'"

"Well, yes I did because we have not had that dose available for quite some time now and the manufacturers no longer make that dose"

He sounded very argumentative.

"Well, I am not trying to start an argument or anything, but I just wanted to say that I think for you to say that about a physician to a patient is very unprofessional"

"Well, I think it is unprofessional for Doctors to order doses of medications that we don't have"

"How am I supposed to know that when I look in my pharmacopea and uptodate.com and it says that that dose is still available? As a matter of fact, that dose is still readily available in this hospital. Patients are getting that dose as we speak. And just so you know, that patient that you told that to was MY Father with MY Mother and MY little girl in the car. So I would appreciate it if, in the future, this would not happen again. Because I wouldn't do that to you! Okay?"

"Okay, thank you."

"No, thank you."

I told the outcome to our clinic pharmacist and she was absolutely appalled as was I. He was such an A-hole to me! And ofcourse he did not apologize or even seem to care.

I discussed this with my parents. They have done business with this pharmacy for over twenty years. Needless to say, they don't do business there anymore.

For what it's worth, my mother called the head pharmacist there who is his supervisor and who she has known for years and he had heard about the incident and apologized profusely.

Too little, too late.

Ooooops!

2008-11-06T17:05:00.000-08:00

I think I made my husband feel bad.

He, in my opinion, is a video game ADDICT. He plays it everyday for hours a day. More than half of his waking hours are spent playing video games (typically online - like World of Warcraft).

It seems like I am always trying to convince him to spend time with me and the baby (or just me - like date night), to no avail. No matter what I try, no matter what I say, no matter what I do. And yes, I have even tried the nonchalant way (acting like I don't care, it doesn't bother me, not complaining, not saying anything). Nothing works.

So today I went to his room and he's on the game and he was online playing with one of his (female) friends on there. I guess she was upset about something...he was explaining that for the past 10 nights or so they were leveling...yada yada yada. I just looked at him. I said, "Well, really if yall have been doing that the last few nights, maybe you just need a night off and spend it with your family" He looked at me like he was thinking 'here we go again'. I went on about how he owes me three date nights (from the past 3 weeks), etc and he turns it around "Why are you always bossing me around...." I explained that I was not bossing him, I just miss him and that when I got married, I expected us to spend time and do things together because that is how I was raised...that families spend time together, NOT that the husband is in one room playing games all day while the world goes on around him. Then I said, "Maybe our daughter will expect that because that's what she see's you do all the time...and maybe she'll look for a husband who spends all day playing video games, but not me." I could tell by the look on his face it hurt his feelings. And I added, "It's just that I miss you and I love you and want to spend time with you." He remained silent.

And now...he remains in his room...playing the game.

History in the Making!

2008-11-04T17:36:00.000-08:00

I am very excited about this election! I voted two weeks ago. I am absolutely glued to the TV - it's going to be a long night (or is it). I pray for the safety and both of the candidate's families regardless of the outcome.

Okay, okay, I'm an Obama Mama...I said it. Please spare me the gossip and rumors - lol. But really, I believe that he is the person who has the drive and potential to shift this country in the right direction. Experience is a great teacher, but not if your teacher sucked (no offense). I mean, if all of the experience was focused on making /supporting the mistakes that brought our country to where it is today, then that doesn't say much. Some people prefer the old white-haired physician. In some cases (not all), this physician who was trained long ago does not know the newest diagnostic techniques or treatments where the young budding physician is well aware of the most up to date standards of care. I guess my point is made. But, it's over now . All the voting is practically done. I just hope whatever the outcome, all of America will be accepting of our new president and ready to make a change.

Now, back to the news...

A Prayer Answered

2008-10-26T09:42:00.000-07:00

At church today, with my little girl in my lap, I said a prayer.

First a little background. My (older) brother this year has moved to Texas and is in a sense restarting his life. He's in school, working, and trying to find his place in life. I am proud of him, but I do miss him and worry about him. I cannot talk to him like I used to because his cell phone is broken. I heard he might be coming down this weekend, but I couldn't catch up with him and had not heard from him.

So back to church, during the special intentions (when we Catholics pray for certain things) and the Priest said "Now, let us now add our own intentions in silenc," I said a prayer. I prayed for my Aunt who past away two weeks ago, I prayed for my family, my husband, of course my little girl, I prayed for my enemies, and I prayed for my brother - that if he came down, he had a safe trip, that he is successful in his endeavors, and just for his well being.

As I sat down, someone tapped my back. I turned around to see, guess who...my brother! At home, all in one peace...at least for now.

Life is Frustrating...

2008-10-24T18:01:00.000-07:00

12 am - baby crying in her crib. I go to her room and get her, make a bottle (I finally weaned), bring her to our room, change her diaper, give bottle, place in bedside basinette, go back to sleep...CNN humming low in the gackground.

5 am - baby crying again. Luckily, husband is awake and in his room (playing video games). At my requests, he gets her bottle ready, I comfort her, give bottle, smell poopy, change diaper, and snooze.

6 am - still snoozing, now through alarm. Morning news is on.

7 am - finally awake. get ready for work while baby sleeps. Discussed investing in the market while it is down with my hubby. back out car so hubby can leave for work. decide I have enough time to make crock pot meal for tonigh (turkey breast with mushrooms). Okay, now I've gotta hurry. I've got two patients in the hospital that need to get seen before 9am clinic. Get Baby Girl Ready.

820 - crock pot is going, baby is ready, and we are out the door. First to daycare.

840 - now in the hospital. My patient with insulin dependent diabetes is stable and ready for discharge home. Wish I could say the same for my other patient from the nursing home. She is a fiesty lady - sweet as candy, but not doing so well. She has heart failure - on of the more challenging illnesses to treat especially in people that also have kidney disease and / or low blood pressure...she has both.

9am - clinic begins, but I'm not there yet.

920 - okay, I am here. Today is a good day. I see mostly patients that I am familiar with - my patients (as opposed to an Attending Physician's or a fellow Resident's). One thing I LOVE about Family Medicine is getting to know and establish a relationship with them and being a part of their lives, helping to diagnosis, treat, and prevent illnesses.

I had a few work-in patients - including two shingles cases in one day (what are the odds). One kiddo (kids always brighten my day) with otitis externa, and a new patient.

1220 - finished morning clinic (a little late) and off to noon conference.

Afternoon - now to recheck on my hospital patient. Labs indicate that she's had a heart attack. Medically manage her and consult the heart doctor. Stress a bit because I have been taking care of and getting to know this sweet lady since the beginning of my Residencty (about 2.5 years) and no matter what we do, even though she feels okay, her labs indicate she just keeps getting worse (renal function, blood pressure, and now...this).

Hang out at the hospital / Resident's lounge until about 6pm. On call (Third year / back up) so my pager is on.

6pm Call hubby to see if he got to pick up the baby. He answers and says "Hold On" and I listen to him order McDonalds. When he finishes, he says he got the baby and asks me how I am. "A little sad now" I say. He asks why. "Well, I made dinner but you are ordering McDonalds" He says "I know you were making dinner...this is just a snack...." We meet at home. The crockpot is ready. I make (instant cheesy) rice. I prepare our plates. Ofcourse he eats maybe two bites of turkey and a bite or two of rice.
WHAT WAS THE POINT OF ME EVEN MAKING IT??? I try to do it all and the main reason I cook, aside from enjoying it, is to keep us from spending money on fast food. UUUGGGGHHHHHHHHHH!

Okay, well, I eat. Baby tries to grab plate, so I feed her. TWO baby food bottles (sweet peas and squash). Then she dozes off for the night. Soon followed by the hubby.

Hopefully my pager will remind silent tonight and I can rest physically and mentally.

My Vacation...Finally!!

2008-10-15T19:53:00.000-07:00

Yay! Vacation! And it is way overdue. I have not had real time off since post maternity leave! This past weekend was spent visiting friends and family in Louisiana and introducing my baby girl to her extended family members! She got to meet her great grandfather who is 91 years old - and in very good health! He is still up and about and can actually drive! She also got to meat her Great Aunt who is, unfortunately, in her last days. She is getting Home Hospice because of multiple strokes that have left her unable to care for herself. She can barely speak or do much of anything and just recently, she completely stopped eating. Although, she did smile when she saw my daughter.

On a lighter note, when we got back home and she saw her Daddy, she got all excited. Then she started saying, "Mmmmm....mmmmm..." kind of grunting like she does when she wants something..."Mmmmummm..mum...mom" My little girl said MOM! Ofcourse dad was jealous.

...and today, all should know no matter what she wears that she is a girl because...She got her ears pierced!

From Old Blog - The Big C

2008-10-10T20:08:00.001-07:00

The Big C
They were doing an exploratory laparotomy...an abdominal surgery where they open up the abdomen to see if they can find what is wrong. And they found it. An adhesion. Scar tissue from a previous surgery. This is what had been causing this 78 year old's sharp abdominal pain. This is what was causing her discomfort, her nausea, her stomach distention. This caused her small bowel obstruction. With the slice of a blade - it was cured. Medicine is truly amazing.
Before closing her up, the surgeon explored the abdomen for any other potential abnormalities. And there it was - a...lymph node. Larger than expected. The path report came back...
Squamous Cell Cancer
Poor lady. While she was in recovery, her family was told the news. Indepth discussion amongst them and the surgeon lead to a decision at the request of the family: Don't tell the patient until the primary source is found and the options are known.
(When a lymph node is positive for this type of cancer, this in most cases means the cancer has originated from somewhere else and has spread into the lymphatic system)
The surgeon called me with the news on my patient.
Squamous Cell Cancer. Primary cancer location unknown. Patient unaware per family's request.
Now that is a tough situation to say the least. I mean, this lady is one of the absolute sweetest patients I've ever had - an absolute sweet heart who came to the hospital for nausea and abdominal pain. Her symptoms improved dramatically after the surgery. Soon, she was eating again, and felt ready to go home.
Further workup the next day and the source was found - cancer of the esophagus...throat cancer.
I talked with the son that evening who assured me that that night was the night. The family had arranged to meet with one of the other doctors on the case and together, they would tell her the news. He couldn't bring himself to do it alone as he originally planned.
I emphasized that it was vital she be informed as soon as possible so that we could get an oncologist (cancer doctor) on board and he could examine her and review her options.
When I came back early the next morning, I spoke with the son who said that the doctor never showed up and she still didn't know. I asked if he'd like me to tell her with him present.
"Yes, please."
Now that I think back on all my patients since med school to now, I cannot remember ever having to tell a person that he or she for certain had cancer. I do remember telling a patient that she more than likely had kidney cancer (but it wasn't confirmed). That was quite similar now that I think about it. I guess it just does not get any easier. I also remember as a med student having a patient with liver cancer, but the doctors told him. In both of those cases, for whatever reason, those two patients died within two weeks. They were really really sick. Their sickness and hospitalization was directly related to their cancer - unlike this situation.
Anyhow, this time...it was me. I was the doctor...I am the doctor. It's up to me to tell my patient that she definitely without a doubt has cancer.
I call the chaplain. I think it very appropriate he be there as I tell this lady...the one who has improved everyday since surgery...this sweet lady who only wants to go home since she feels better...to tell her she has cancer.
I walk in the room with the chaplain. The son is there. He knows the plan...and so I begin.
The one thing I do remember learning in medical ethics is that once you say the word CANCER, the patient likely will not hear anything else.
"Ms. Smith**, I just want to give you an update of what all is going on..."
I take it step by step starting with what they found during the surgery and as soon as I say the C word, she screams, "CANCER!! Oh my goodness! Oh my goodness! No! No!" and she screams and cries, cries and screams. I pause. Thank God the chaplain is there. Thank God her son is there. I give her time as I hold one of her hands. Her son has the other hand. I explain the rest of the findings and where we go from here. The chaplain leads us in prayer.
And just like that, her life is turned upside down. A curveball thrown at her.
Options for her include what's called palliative chemo. Anything palliative means it may help but it certainly won't cure. Her and her family are still deciding what to do.
Makes me wonder.
If she had never gotten the small bowel obstruction and came to the ER for nausea and abdominal pain, the positive lymph node would have never been found, a search for cancer would have never been started, and the fact that she had cancer would not have ever been known.
But was it a good thing that the cancer was found...or would she have been better off never knowing?
(**Names and some details changed to protect identity

From Old Blog - No one deserves this

2008-10-10T20:07:00.001-07:00

No one deserves this...
My night was just beginning. First, a lady with classic appendicitis. You M.D.'s know what I'm talking about. So often we see "abdominal pain" that turns out to be…nothing…or at least nothing major, but this lady had classic periumbilical pain progressing to right lower quadrant pain, rebound pain, rosvig's sign, mild leukocytosis, tachycardia,..everything. OK, enough doctor talk.
After getting her squared away with the surgeon, the chest pain guy comes in. But this is not the everyday chest pain…nor is it the heart attack chest pain. This is the chest pain of a drunk who's blood alcohol level was greater than twice the legal limit although he says he hadn't had a drink in a few days. A guy who reeks of alcohol yet cannot understand why he passed out.
Then there's the person with a corneal abrasion (eye tear) and one with a nose bleed and a kid with an ear ache, etc.
But the one thing that…caught my attention and actually tugged at my heart in the midst of this ER night…was a girl. Seven years old. The nurses told me - victim of sexual assault - RAPE. Child Protective Services is there. Her mom is there and I can tell mom is holding back tears. Then I see her - a sweet, playful child who looks up at me and, in spite of her situation, she smiles at me. I introduce myself and I ask "What's your name?" She answers politely. She's only seven. Doing well in school. She didn't deserve this. No one deserves this…especially a young, helpless child who cannot defend herself. After examining her I ask, "So do you know what you want to be when you grow up?" "Yeah, I want to be a doctor just like you!"
Precious words form a sweet girl in a horrible situation.
(As always, details are omitted and some facts changed to protect identity.)

From Old Blog - Wrap It Up!

2008-10-10T20:06:00.001-07:00

WRAP IT UP!
A 25 year old female came into clinic to see one of my colleagues because she was "Just not feeling well"...feeling tired, fatigued, and having a bad sore throat for the past few weeks. On physical exam, her mouth and throat had white streaks. She had a low grade fever. Scrapings of the streaks in her mouth and microscopic view revealed yeast. Yeast in the mouth is very uncommon except in babies and in the immunocompromised (i.e. diabeties or...HIV/AIDS). After my colleague talked with her, she agreed to get tested for HIV.
This young, beautiful female, devoted wife, and loving mother, was...that day...diagnosed with HIV - the virus that causes AIDS. She came in thinking she just had a bad cold and now, her life is forever changed.
The circumstances to how or when she got infected is unknown.
Was it from her husband? How then will she confront him? How long has he had it? Did he even know?
Was it acquired before she was married and she just did not know? If so, how would she tell her family...and is her child infected?
Was it from a lover? How will she now break the news to her husband?
How will this affect her family? Her friends? Her life?
People, you cannot tell by looking at someone if they have something. It only takes one time. Don't ever get so caught up in the moment that you gamble your future and your life! It can happen to you, so, two things...
(1) GET TESTED! Better to know early and start treatment as soon as possible to have a better outcome...
and
(2) WRAP IT UP! ALL THE TIME! EVERYTIME! THE WHOLE TIME!

From Old Blog - HUG YOUR MOM!

2008-10-10T20:04:00.001-07:00

GO HUG YOUR MOM!!! Current mood: sad
I sit here while on call after a CODE BLUE. Sixty three year old Hispanic lady, mom of seven, admitted to the hospital yesterday, found to have a mass in her chest. While in her hospital room this morning using the bathroom - her heart stops and she stops breathing - CODE BLUE. Inspite an hour of trying to get her back, our efforts are futile.
She is pronounced dead...
...and her family arrives. The first daughter to arrive can look at our faces and know that her mom is now gone forever.
...and she cries
...and cries
...and cries
...inconsolably.
In my career, I see a great deal of death. Many times it is expected - the man with pancreatic cancer x 4 months; the elderly woman with heart failure, diabetes, and end stage dementia; the man with severe chronic obstructive pulmonary disease (COPD) and respiratory failure; and even when expected it is hard enough. But when one day everything is fine and over the next 24 hours you find out Momma has a tumor in her chest...and before you can even comprehend the fact that it might be cancer...she dies?
It's just hard.
So, hug your mom. Tell her you love her. Tell all those that you love what they mean to you every time you get the chance. You never know when their time will come.
***some details changed to protect privacy***

From Old Blog - A Baby Story

2008-10-10T20:01:00.000-07:00

Friday, April 11, 2008
A Baby Story
Although I was due to have Baby Girl March 14th, I had to be induced early because of Preeclampsia. Initially the induction date was to be the 13th, however, after some lab work returned, it was decided that Sunday March 9th would be the day. So that morning we were all set and my hubby and I arrived at the hospital at about 8 am. I was extremely nervous and anxious. Although I was excited to finally be meeting Baby Girl, I was scared to death of Labor.
It was a little comforting to already know the nurses and they were all very friendly. So they got me settled and ironically, just before they gave me the medicine to start contractions, I had one on my own. They checked me and my cervix was closed thick and high so I knew it would be a loooooong day. They gave me cervadil and the contractions picked up. I could feel them pretty well though they weren't painful. Shortly after noon, they gave me my second dose and checked me - about 1-2 cm. I went ahead and requested the pain meds before the pain kicked in. As soon as they gave it to me I started telling my hubby how I could feel it kicking in and I was feeling woozy and the room was bouncing…then I was out.
I woke up a few hours later in severe pain and they checked me, I was 4 cm, then they gave me some more pain meds and again, I was out. Thanks Stadol. Oh, and if I hadn't been so out of it, I would've asked for the epidural then. Anyhow, I woke up a few hours later again in severe pain, was checked - 7 cm. I was begging for pain meds and the nurse said I'd get the epidural as soon as the anesthesiolgist was available. Apparently he was in on an emergency case. He finally came, but had a little trouble because I was involuntarily tensing up every time he tried to stick me. He finally got it after 3 sticks - only to have it come out before he taped it. So he had to stick me yet again. Traumatic but worth it.
After that it was smoother sailing. Next time she checked me (around 3 am the next day I believe) I was complete and ready to push! I called my parents, Toney called his, the doctor returned, my mom came in, and about 2 hours later, I just remember hearing her cry as my tears of distress turned into tears of shear joy and then I remember my mom saying, "Oh she's here Juanita! She's finally here! She's so beautiful!…" And I remember looking but I couldn't see her. My husband cut the cord and they put her up on my chest and her little eyes were just were just looking up at me trying to focus. And I just stared at how beautiful she was.
And I nursed her.
Wow, after 21 hours, she was finally here. Heck, after 39 weeks of being in my belly, she was finally on the outside, looking at me face to face. Fascinating! And yes, how beautiful. Head full of hair, golden skin, she did look a little like me - thus she has my middle name.

Born 5 am
March 10th
5 lbs, 10.5 oz
18 inches

From Old Blog - What About My Disability???

2008-10-10T20:00:00.000-07:00

"What about my Disability??"
Monday January 7
35 year old male comes to clinic with cough, congestion, etc...no fever and further history, physical exam, and work up suggests no sign of serious illness...more like the common cold. Symptomatic treatments are given (no antibiotics). A note for work for that day is given (since he missed work for his appointment). He is to return to work Tuesday...
He questions the receptionist "She must mean next Tuesday right? Return to work next Tuesday?" "No she wrote you can return tomorrow."
He stomps back to where I am, "You didn't mean tomorrow, you meant next week right? Return to work next week?" "No sir." He goes home disappointed and upset but not before leaving short term disability papers he wanted me to fill out so that he can recouperate from his cold.
He returns to clinic today and sees a colleague of mine. Same symptoms. He again brings another copy of short term disability papers for my colleague to complete, then asks, "The doc I saw Monday said I could go back to work now - aint that crazy?" "Um, no" my colleague responds. "You can return to work" Me nor my colleague would complete the disability papers because he did not qualify. He does not have a disablity. I see people working all the time with cough, congestion. I've had the common cold 3xs since I've been pregnant and I'm still working. (Aside: the key here is of course frequent thorough hand washing)
Since when does having a cold or lingering cough equal disability??? Did I miss the memo?
That reminds me of a patient I had last year who wanted disability because she has reflux.
I just don't get it!

Short Vent

2008-10-08T20:52:00.000-07:00

It is really nice to come home from a 14 hour day at work only to have a crying baby handed off to me and to be treated by my husband as if I've done something wrong.

My First Post

2008-10-05T13:38:00.000-07:00

I am coming over from aol journals where I kept a log of my experiences in Medical School and Residency. Briefly, I am in my third (and final) year of my Family Medicine Residency. I am in the process of getting my license, finding a job, and as always, taking care of patients and assisting Interns and other Residents. And ofcourse, always learning.

But even more importantly, I am now the mom of a beautiful six month old baby girl!

So between my full time job, being a full time mom, and trying to be a good wife, keep house, pay bills, etc, my life can be quite demanding at times. I plan to try to keep this journal updated if time allows.