Rural Doctoring

Rural Hospitalist Tip #1: It's Just Like Falling Off a Bicycle

2010-04-23T13:00:38-07:00

So I've been having one of those funky runs of call in which it seems everyone crashes on my watch. Patients who were as stable as can be on the previous shift suddenly become obtunded or oxygen-starved the minute I've gotten sign-out and the other hospitalist(s) have left the building. This happens to everyone--after all, the patients are in the hospital for many reasons, one of which is the risk of getting sicker--so I'm trying hard not to take it personally.

Anyway, the upshot of all this chaos is that I had to intubate two patients this month, which is more than I've done in the past five years. I haven't been the point person for intubations since I was a second-year resident covering the ICU and NICU. When you're a resident, you'll intubate anybody, just to get the practice. (This is the only reason to hang around the OR or ER, in my humble opinion--to pick up experience in managing airways.)

The thing is, once you become a real doctor, your priorities shift and you start doing everything in your power to avoid intubating patients--unless you become an anesthesiologist or an emergency physician, the former having committed herself to the vagaries of expertise in airway management, and the latter exposing herself to the slings and arrows of whatever shows up during her shift in the ER. The rest of us leave residency and realize the path to respiratory failure is paved with opportunities to stave off intubation, such as well-timed discussions about the limits of care, prompt initiation of noninvasive ventilatory support modalities such as BiPap, and frequent patient assessments to make sure you've got the right diagnosis and are managing the problem aggressively.

In fact, avoiding needless or futile intubation is a much more complex and difficult art than getting an endotracheal tube past the vocal cords. I'm not saying intubation and mechanical ventilation are bad things, but they are invasive and probably not appropriate for every patient, so it behooves a hospitalist to anticipate problems, communicate effectively with patients/family/staff, and deploy alternative therapies appropriately before rushing to the bedside with laryngoscope in hand.

Having said all of this, sometimes the deck is stacked against you and you have to intubate a patient who is deteriorating. Suddenly, all the expertise you've developed in avoiding intubation makes you feel a bit rusty. You start to wonder if you should call the anesthesiologist to get the tube in, because she's better at it than you are and you don't want to fumble with the tube and the scope in front of all the staff.

If you're a rural hospitalist, you might not have an anesthesiologist available to intubate the patient, and maybe the ER doc is tied up with a crisis of her own, so all eyes are back on you to get the job done. Fortunately, a few factors are very much in your favor:

1. Kinesthetic memory is a wonderful thing. Once the tube is in hand, the memory of all those R2 intubations come rushing back and the next thing you know, you're looking at the vocal cords and are as amazed by their space-alien beauty as you were the first time you saw them, all those years ago.

2. Technology has improved by leaps and bounds since you were a resident. Of the two intubations this month, I had a GlideScope available for one, which was a real Far Side Caveman moment for me. Instead of struggling with a stainless-steel laryngoscope and worrying about dislodging teeth, there I was holding the video baton and rocking the plastic introducer back just enough to see the cords on the portable video screen. A piece of cake. A monkey could do it, assuming it passed gross anatomy, and if I passed I'm pretty sure a monkey can too. The GlideScope is going to be a huge boon to the rural hospitalist, especially in dreaded Weird Jaw and Neck From Hell scenarios.

It's like falling off a bicycle. Thank God.

This Says It All

2010-04-18T20:47:42-07:00

OK, Maybe Congress Can Gnaw on THIS Problem Next

2010-04-03T22:34:34-07:00

The pediatric rooms at Nordsrom are equipped with special alarms to deter would-be kidnappers. When activated, they trigger a truly appalling siren at the RN's station, the kind of sound which can strip paint off the walls. Unfortunately, they malfunctioned the other day and would not turn off. We were all in danger of being driven insane, but fortunately the Plant Ops guys managed to rig up a noise-deadening system:

This is a microfiber mop balanced on top of an adjustable desk chair. You can't see it, but there's a 3-ring binder between the two to keep the mop tightly in place. It didn't kill all the sound, but it made the decibel level tolerable for a couple of hours until the snafu was fixed.

Looks Familiar to Me

2010-03-13T19:48:51-08:00

I was random link-clicking today and found this photo gallery, which could be a portrait of an average hospitalist night at Macy's.

This is Hard to Say

2010-03-04T09:17:31-08:00

Of all the recent professional upheavals I've survived recently, there is one which has posed a particular barrier to writing this blog: my departure from childbirth services. You heard that correctly--I'm no longer attending births. Doing so has been such a huge part of my professional identity, and my identity as the writer of this blog, that it has been really difficult for me to talk about the change without succumbing to despair. Today I feel ready to blurt out the truth, and I hope this will release some of the inhibition I've experienced in my writing.

I knew my participation in maternity care would be diminished after my departure from Gimbels. The Birth Center there is predominantly run by family doctors and is, as I have described in the Birth Stories, a uniquely tolerant environment for women to have their babies. Unfortunately, the environment at Macy's and Nordstrom is closer to the standard obstetrical norm: run by OB-GYNs supervising CNMs, unfriendly towards extending privileges to FPs, surgically oriented, and regressive in birth policies (i.e. no VBACs, no water birth, an emphasis upon spinal anesthesia for labor relief, etc.)--so working at these new hospitals meant a significant paradigm shift if I were to pursue childbirth privileges.

The chief medical officer at Macy's is a friend of mine, and would have supported my application for privileges at the Labor and Delivery unit. Two of the older OB-GYNs would have been glad for the help in their laborist pool, but they also had the ulterior motive of wanting me to work for them in their so-called "primary care" practice, which would have consisted of providing preventative care services (Pap smears, mammogram referrals, GI referrals, screening labs) to well-insured patients, perhaps managing simple chronic illnesses (hypertension, dyslipidemia), but referring all the messier aspects of real primary care--pain management, mood disorders--back to the already-overburdened rural health care system. The unspoken understanding is that I would keep the referrals for these well-compensated preventative services within Macy's and its satellite services. The truth was that this "primary care" practice was nothing more than a venue for cherry-picking revenue-generating opportunities from the true spectrum of primary care, and I didn't want to have anything to do with it.

Even though I was tempted to apply for childbirth privileges at Macy's just to piss everyone off and shake the political tree, I finally decided this was a lousy use of my psychic and creative energies. I'd had enough confrontations with the administration of Gimbels and the band of incompetents running Xpress Hospitalists during the past year and didn't feel like rolling up my sleeves for any new ones.

The other alternative was to continue delivering babies at Gimbels, but the logistics of this option proved overwhelming. How was I supposed to be a contributing member of the OB call pool there if I was spending a week at a time at Nordstrom, over an hour's drive away, and another week of night shifts at Macy's? How was I supposed to provide prenatal care at my clinic? Sure, I could be on call and at clinic on my off days, but then this put me back into the category of Doctors Who Work All The Time. I used to be one of these doctors who never take a day off, who is committed to work twenty-seven days every month--hell, I even enjoyed the experience, but since Noo's illness I don't feel I can drop everything and run to the hospital to catch a baby all the time.

Dropping hospitalist work and providing prenatal care full-time was not an economically feasible option at the FQHC practice where I used to be based. I was paid $400/day to see 20+ patients in clinic, and $100/night on call. If I was lucky enough to attend a birth, I was paid $300; however, if the labor concluded in a C-section, I was paid $100 to assist the surgeon. These fees applied to quick labors and week-long inductions alike. In the case of a multi-day labor or induction, I might earn less for attending the resulting birth than I would in a day of clinic. Of course, if I missed a clinic to be present at a birth, I lost the $400/day I was counting on for being scheduled to work that day. Certainly I could have made a living on the basis of these numbers, but just barely, and at the expense of going back to working almost every day of the month. Meanwhile the size of the living I have to earn has increased noticeably since Noo's illness, and as I mentioned above, so has the importance of balance work and time off.

Finally, and most important of all, I haven't had the emotional energy to give to being fully present at a woman's labor since Noo's illness. I believe emotional presence is essential in a birth attendant, and I don't want to rob a woman of that presence during her labor. Even though I've been emerging from the Mighty Blue Funk which has oppressed the past six months, I haven't felt the return of that broad streak of courage, humor, and tolerance for the unknown which used to be my greatest asset in the labor room, and I won't go back without it.

I don't know what the future will bring, if I will return to the practice of maternity care I used to love so much. The risk of letting the practice lapse is that I might lose the ability to keep privileges at a hospital where I might be of service, but the benefit--for now--is a bit more sanity, a reasonable pace of life, and more time to recover and awaken to this new life.

Making Time and Space

2010-02-23T11:02:19-08:00

In a spread from one of my recent visual journals, I wrote: "GOTTA FIND TIME FOR THE CREATIVE LIFE...No more excuses! Of course I'm busy, but I don't have to sign up for every unfilled shift and I don't have to spend all my downtime surfing the damn internet and shopping aimlessly. I can be working in this mixed-media journal or writing, which has always been in my heart to do."

(Media: watercolors, acrylics, collage elements, rubber stamps by Traci Bunkers and others , paint pens.)

I did this spread just before Christmas, during a particularly brutal cluster of hospitalist shifts at Nordstrom. Since then, I managed to slug my way through a lighter January schedule--without crying at Macy's!--and am now in the middle of a three-week break before I dive back into work again. This break doesn't quite rise to the level of a mini-retirement, but it has freed up enough time for me to carve out a plan for achieving enough space and time for the creative life

The first space is the extra room at the front of my house, meant to be an office or a den but largely used--since we moved in--a forlorn storage area, a dumping ground for empty boxes and stuff on its way to the recycling center. Over the past two weeks, 96% of the crap has been moved out, sorted, recycled, disposed of, moved to storage, and generally expelled from the house--and replaced with a vintage Chinese writing desk, bookshelves and organizers from IKEA, and soon-to-be-installed cork tiles to create an ideal wall behind the desk.

The second space is half of the two-car garage, which has been, up until now, home to approximately 300 boxes of utterly useless crap Noo and I have moved around with us for years, and the 300,000 spiders who took up residence in this neglected space. Now the garage is half gym, half mixed-media studio, and although there are still a half-dozen boxes to sort through, and perhaps 600 remaining spiders to evacuate, the upshot is that I have been able to move all the paints, acrylic media, files of ephemera, markers, pencils and glue sticks which have been ferreted away inside the house into their own dedicated space. Now my house feels 100% larger, and I know where to go to do what I need to do. No more will have to clear away ink pads and acrylic palettes so that poor old Noo has space to slice up strawberries on the kitchen counter.

Carving out time for the creative life is more difficult. Other than curtailing my online time, I have also restricted myself to no more than seventeen hospitalist shifts per month, which is a respectable full-time commitment but not as insane as the 21-shift extravaganza I completed in December. All my downtime that month was spent in a vegetative state, which didn't do much for my well-being, and nothing for my creative output. The next challenge is going to be imposing some kind of writing schedule which will fit into my week-long absences in Extra-Rural, and adapt to the upside-down nocturnalist routine at Macys. Still, this is the closest I've ever had to having space and time enough to do what I really want to do.

Brave New Blog

2010-02-17T09:46:10-08:00

During my recent silence I spent a lot of time thinking about the original vision I had for being a rural family doctor. In this vision, I provided full-time primary care, including inpatient coverage for all my patients, whether they were kids, old people, or laboring women. I was going to be a salt-of-the-earth, old-fashioned family doc who was present for birth, death, and the messy interval between the two. For a brief period--about a year--I lived a close approximation of this vision, and although it was a rewarding and happy time, various factors ultimately led me to transition to full-time hospitalist work.

Anyway, the various transitions I've made over the past few years raised a number of unexpected difficulties, including the direction this blog was to take. When I first decided to take up blogging again, I was committed to the Dream of Family Practice and to providing a rural perspective to the medical blogosphere. I wanted to reveal the various aspects of a rural family doctor's practice and personal life, and thus the blog was originally quite narrowly topic-focused and had a generally informational and pragmatic tone. I wanted the blog to be useful to readers, and it was gratifying when medical students and other family doctors wrote to me with questions about rural practice and how to prepare for the kind of life I was leading.

As the DoFP gradually unwound, I found myself confronted with an uneasy impostor phenomenon. This blog had been established upon my life as a full-spectrum rural family doctor, and as time passed, major chunks of that identity were falling by the wayside: first, inpatient pediatrics, then inpatient medicine (as a part of primary care, not hospitalist medicine), and finally ambulatory primary care. Sure, I had experience in each of these areas, but I didn't feel justified continuing to write about them as if I were still in the middle of developing professionally within these areas.

More recently, I have come to question the usefulness of my original approach to blogging about rural life. Even now, I receive emails asking me whether I would choose this life again. The answer to that question is truly enormous and encompasses things completely unrelated to the practice of medicine, and now I realize my topic-focused and pragmatic blogging barely touches the tip of the rural lifestyle iceberg. How useful is this approach, then? Hm.

Then there are my own dreams and priorities. Noo's critical illness last summer abruptly underscored What Is Really Important in Life, Because Life is Brief and Unpredictable. Now that she is recovering nicely, and we have made important changes in our lifestyle to ensure her well-being, I have had more time to inventory my own goals. The outcome of this deliberation is this: I am going to dedicate my creative energies towards the fulfillment of my primary identity as a writer. Because this was my original dream, and even though medicine evolved into a related set of important goals and identities, the eight-year old part of my spirit still says, Yeah, well, that's all nice but--I'm a writer. And she will not be censored. Trust me, I've tried.

What this means for this blog is a partial retreat from its original topic-driven pragmatism towards a less predictable, in-the-moment creative abundance of posting. I'm going to share progress in writing projects, both traditional written work as well as mixed-media visual journaling I have been pursuing in an effort to express some experiences which simply don't reduce well into linear written form. And I'm going to keep writing about my occasional professional triumph, and daily professional embarrassments, as I go along, but only as the mood takes me. On days when I feel pragmatic--and there are many--you'll get case reports, Birth Stories, and career low-downs, but on days when I am seized with the image of frogs singing in my neighbor's field, you'll get a photograph, or a round snippet of thought which the song itself revealed. In this way, I think you'll get a true glimpse into this rural family doctor's life.

No, This Blog is NOT Dead

2010-02-15T14:29:26-08:00

It may have been a while, but I think I'm back in the swing of things. Thank you to all the kind people who reached out to me via email and comments. To put everyone's mind at rest, let me say first that everything is going well with Noo's health and reassure you all that my recent silence was not the result of yet another disaster in my personal or professional life. The usual daily mini-crises continue apace--a tree knocked down into my driveway, an infestation of ants in the pantry, five piles of delinquent charts waiting for me at Macys--but these minor annoyances are a welcome distraction compared to the complete upheaval I experienced last July, when Noo was so desperately ill and I bowed out from a job which I both loved and hated at Gimbels--all in the same week.

Looking back, it is clear to me I suffered an emotional tailspin during the second half of 2009. Not that anyone really noticed, because I was the most plausible-looking crazy person in Rural County during that time. I showed up to work on time, did a damn good job, smiled at everyone's jokes, maintained my reputation for good-old-girl collaboration at my new jobs--but inside I suffered from a nihilistic creative frenzy. I've done this before: thrown myself headlong into multiple reading projects, creative endeavors, and aimless accumulation of things (I have a few dozen collections in my life, including books, ethnographic art, tacky vintage brass wall-hangings, and a category of memorobilia I refer to by the politically-incorrect term "Chinxploitation"--stereotypical representations of Chinese people as coolies, opium-smokers, elaborately-coiffed Mandarins, etc.) I tend to succumb to these frenzies during times of emotional uncertainty, as if there is a greedy, wild, unsatisfied creature which takes over my self-control and proceeds to devour every fleeting distraction without plan or reference to any of my real needs.

Fortunately, this frenzy didn't last as long as it has in the past. Yes, I acquired a couple of bookshelves worth of reference material, several pieces of ethnographic art, a pile of prints from 20x200 which have yet to be framed, a bagful of toy cameras, and more brass Art Brut owls I know what to do with, but I also managed to wrestle the beast back into its lair without disrupting my household too much, although there might be some protests once I get those owls hung on the wall.

The good thing about these frenzies is that I usually emerge from them with a bit more insight into my turbulent emotional substrate, and what I realized as I slammed the door on my Greedy Inner Beast was that I needed to get back to what really matters to me, instead of trying to meet the pre-set ideal of what I Thought I Should Be. This sounds so elementary, the kind of thing an experienced viewer of Oprah and Dr. Phil might come up with, but like so many trite statements, there's a wide ribbon of truth running through it.

What this has meant for me is a conscious letting-go of the original Dream of Family Practice, an acceptance of the pragmatic career choices I've been making lately, and an honest reappraisal of how I want to use my creative energies. For a while, I wasn't sure how this blog would fit into this Brave New World, but now I have a glimmer of an idea. About that, more anon. For now, just know that we are all alive and well, blog included.

The Least Sexy Holiday Invite, Ever

2009-12-16T23:33:53-08:00

The cat is adorable, but the offer--not so much:

Never Mind the CT Scanner

2009-12-10T13:26:40-08:00

Here's the most important piece of equipment in the hospital:

You got it, the ice machine. Just ask all those parched patients on Med-Surg which device they'd take with them to a deserted island.