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The cardinal sin of medicine?

An Emergency Medicine physician blogger calls laziness the “cardinal sin of

How did this quality achieve such status?
TrenchDoc explains:

Simple. It is the ONE thing that we as
physicians can control. We cannot prevent patients from smoking and driving
their minivans into light poles. We cannot help that patients have myocardial
infarctions without any symptoms whatsoever. We certainly can not force them to
take medicine or have routine checkups. We CAN however be careful,
double-checking and unassuming diagnosticians. I don’t mean by this that we
should order a whole boatload of tests on each patient… quite the contrary… I
mean we should SPEND THE TIME with the patient to find that one unlikely detail
that is the key to solving the problem.

Honestly though, being lazy, quick and
cheap are the easiest of sins to commit in our vaunted system. We pay
physicians in this country basically upon the number of procedures or the
amount of patients they care for per hour. Eventually, poorly directed
efficiency gives way to poor quality of care and to be honest, I am as guilty
as anyone when it comes to missing important clues from a patient.

In his blog post, TrenchDoc goes on to describe a terrible
case of a mentally disabled woman who fell out of an electric shopping cart at
a Value Mart.  She complained of severe back
pain and got every imaging study under the sun (which showed a normal
spine).  She was discharged from the
Emergency Department, only to be readmitted to another ED weeks later when her
pain was still too great to bear.  This
time she said it was her leg that hurt… take a look at the horrible fracture
she had that was missed at the first ED.

I have argued that one of the major causes of decreased
quality of care is reduced patient-physician interaction time.  We are so pressured to rush through our
history and physical that we often miss the diagnosis, furiously documenting
everything without mentally processing what we’re doing.

I agree with TrenchDoc’s call to spend more time with
patients, though time doesn’t come easily.
How do you think we can help physicians find more time to be with their

This post originally appeared on Dr. Val’s blog at

Hanging in the calorie balance

Alright so now you know I love cookies. But this is just a small part of my culinary
weakness – I actually like all food, and the less healthy it is, the better it
tastes (in my opinion). Of course I try
to eat lots of green leafy veggies, lean meats, and citrus fruits… but how can
one resist hazelnut gelato or Camembert cheese?
Or who would turn up his nose at Kobe
beef with truffle oil-drizzled mashed potatoes and butter? Or what about hot scones and clotted cream
with strawberry jam?

Sigh. I must admit
that my extreme enjoyment of all things gastronomical has landed me in quite a
position on the exercise side of the calorie balance equation. I’ve never been a natural athlete though I do
like getting out into nature.

In fact, I’ve been jogging (one could not describe my
efforts as running) since I was a pre-teen.
I like the minimal hand-eye coordination required for the sport, the
virtual inability to let teammates down (running by yourself has a low risk of
disappointing others), and the freedom of being able to go wherever you like –
breathing in the fresh air, taking in the landscape, and letting the mind

And so I’ve been trying to get back into jogging as this
winter has been the most sedentary of my life.
I am now experiencing what my profession calls “deconditioning” and have
been in near awe at my body’s ability to lose its capacity to perform something
it’s been doing for decades – all within the span of <6 months.

I was recently amazed by how difficult jogging had
become. My legs felt heavy, my heart was
pounding, everyone was passing me on the trail… I was becoming quite
discouraged, when I suddenly happened upon a brilliant idea: rope someone else
into my suffering!

I approached an unsuspecting friend of mine with a proposal:
“would you like to jog with me 3 times a week in the early mornings?” I tried to make that sound as appealing as
possible, putting on my best hopeful grin while sizing her up and wondering if
she could tolerate my slow pace. Much to
my surprise, she responded with an enthusiastic “yes!” She said that she was “not any good at
running” but was trying to get back in shape and would welcome some

And so the two of us have been trundling along a running
trail each Tuesday, Wednesday, and Thursday morning for the past month. We’ve had a lot of fun catching up on each
other’s lives, and somehow the exercise has become less arduous and more

So what’s the moral of this rambling post? Exercise is hard – it’s not always fun, and
if you haven’t done it in a while, you’re guaranteed to feel fairly embarrassed
by your inabilities at first. But don’t
give up! Find a nice exercise buddy and make
time to do it regularly. That way you’ll
be healthier, happier, and able to eat occasional rich food with less guilt!  Anyone out there been struggling to get more active?

This post originally appeared on Dr. Val’s blog at

Baking cookies, Part 2

One day I was consulted on a patient in the surgical
ICU. It is uncommon for rehab physicians
to be called to the SICU, and so en route, I pondered what I might find. Maybe a multiple trauma patient who needs a
walker or chest PT?

As it happened, the patient was a 21 year old male who had
gotten into a fight in the West Village. He was hit on the head with a blunt object, resulting
in a subdural hematoma and severe brain injury.
He was intubated, sedated, and expressing decerebrate posturing (a
really bad sign).

The surgeons had called me because they were concerned about
pressure ulcers and contractures. They
wanted to initiate physical therapy and stretching exercises to make sure that
his Achilles tendons didn’t shorten irreparably as his feet were pointing
downward in the bed. Although I thought
it was great that the surgeons were planning ahead like that, truthfully I didn’t
think the patient would ever walk again, or perhaps even survive the SICU. The level of brain injury was just too

I wrote orders for daily physical therapy, got him some Multi Podus Boots, and recommended frequent turns in bed.
I figured I’d never see him again as I was scheduled to change rotations
and transfer follow up of this consult to another resident. It was a tragic case.

About 2 months later I began an inpatient rotation and was
listening to the story of several patients whose care was being transferred to
me. As the resident presented the final
one, I thought the story sounded familiar.
A young man out partying with his friends, got into a fight, sustained a
severe brain injury after being hit in the head…

“This isn’t the guy I saw in the SICU 2 months ago, is it?” I asked the resident.

“Yeah, that’s the one!
I remember seeing your note in the chart. The PTs did a great job with his ankles – he could
stand on them just fine when he got up.”

“Dude, no way! When I
saw him he was posturing in the SICU… this guy actually recovered?!”

“Yeah, I know… he’s the first one I’ve ever seen like this. Do you wanna see him?”

“Heck yeah,” I said, “I’ve got to see this with my own eyes.”

My colleague led me down the hallway to the occupational
therapy kitchen. As we got closer, a
wonderful chocolatey smell filled the air.

“What smells so good?” I asked.

“Oh, the patient is making cookies with the occupational
therapists. He’s learning how to cook
and take care of himself.”

I rounded the corner into the kitchen and there was a young
man, handsome and healthy, pulling a tray of cookies from an oven – I could barely believe it was the same

“Hey doc,” he said to me – not recognizing me of course, but
friendly nonetheless. “You want a

“I’d love a cookie,” I said, remembering the last time I had baked them.

“I believe that this is the best cookie I’ve ever tasted,” I
said, looking at the man with tears in my eyes.

He grinned from ear to ear.

This post originally appeared on Dr. Val’s blog at

Baking cookies, part 1

When the president of a country dies suddenly, they say that
the citizens forever remember where they were, and what they were doing, when
they first heard the news. I’ve heard people
discuss their personal circumstances when they received word that President
Kennedy was shot. For some reason, that sort
of news is a memory fixative, preserving individual experience along with
national tragedy.

For me, 9/11 was one of those events. I was getting off a night shift rotation at a
hospital in lower Manhattan, sitting in morning report, dozing off as usual –
my eye lids sticking to dry corneas, my head feeling vaguely gummy, thoughts
cluttered with worries about whether or not the incoming shift of residents
would remember to perform all the tasks I’d listed for them at sign out.

And as I dozed off, suddenly our chief resident marched up
to the front of the room, brushing aside the trembling intern who was
presenting a case at the podium at the front of the dingy room. “How rude of him” I thought hazily, as I
shifted in my seat to hear what he had to say.

“Guys, there’s been a big accident. An airplane just crashed into the World Trade Center.”

Of all the things he could have said, that was the last
thing I was expecting. I shook my head,
wondering if I was awake or asleep.

“We don’t know how many casualties to expect, but it could
be hundreds. You need to get ready, and
ALL of you report back to the ER in 30 minutes.”

I thought to myself, “surely some Cessna-flying fool fell
asleep at the controls, and this is just an exaggeration.” But worried and exhausted, I went back to my
hospital-subsidized studio apartment and turned on the TV as I searched for a
fresh pair of scrubs. All the channels
were showing the north tower on fire, and as I was listening to the news
commentary and watching the flames, whammo, the second plane hit the south
tower. I stared in disbelief as the “accident”
turned into something intentional. I
remembered having dinner at Windows on the World the week before. I knew what it must have looked like inside
the buildings.

I was in shock as I hurried back to the hospital, trying to
think of where we kept all our supplies, what sort of injuries I’d be seeing,
if there was anything I could stuff in my pockets that could help…

I joined a gathering crowd of white coats at the hospital
entrance. There was a nervous energy,
without a particular plan. We thought
maybe that ambulances filled with casualties were going to show up any second.

The chief told me, “Get everybody you can out of the
hospital – anyone who’s well enough for discharge home needs to leave. Go
prepare beds for the incoming.”

So I went back to my floor, recalling the patients who were
lingering mostly because of social dispo issues, and I quickly explained the
situation – that we needed their beds and that I was sorry but they had to
leave. They were actually very
understanding, made calls to friends and family, and packed their bags to

And hours passed without a single ambulance turning up with
injuries. I could smell burning plastic
in the air, and a cloud of soot was hanging over the buildings to the south of
us. We eventually left the ER and sat
down in the chairs surrounding a TV in the room where we had gathered for
morning report. We watched the plane hit
the Pentagon, the crash in Pennsylvania…
I thought it was the beginning of World War 3.

The silence on the streets of New York was deafening. Huddling inside buildings, people were
calling one another via cell phone to see if they were ok. My friend Cindy called me to say that she had
received a call from her close friend who was working as a manager at Windows on
the World. There was a big executive
brunch scheduled that morning. Cindy
used to be a manager there too… the woman’s last words were, “the ceiling has
just collapsed, what’s the emergency evacuation route? I can’t see in here…
please help…”

That night as I reported for my shift in the cardiac ICU, I
was informed by the nursing staff that there were no patients to care for, the
few that were there yesterday were either discharged or moved to the MICU. They were shutting down the CICU for the
night. I wasn’t sure what to do… so I
went back to my apartment and baked chocolate chip cookies and brought in a warm,
gooey plate of them for the nurses. We
ate them together quietly considering the craziness of our circumstance.

“Dr. Jones, you look like crap” one of them said to me
affectionately. “Why don’t you go home
and get some rest. We’ll page you if
there’s an admission.”

So I went home, crawled into my bed with scrubs on, and
slept through the entire night without a page.
disaster had only 2 outcomes – people were either dead, or alive and unharmed –
with almost nothing in between. All we
docs could do was mourn… or bake cookies.This post originally appeared on Dr. Val’s blog at

The scream

An elderly woman had had a
cardiac arrest and was resuscitated long
after a lack of oxygen had permanently damaged her brain. Her daughter remained at her side day in and
day out in the Medical ICU, keeping watch on a hopeless situation.
Many staff had encouraged her to go out and get some fresh air, to take
care of herself… but she was compelled to stay with her mom 24-7 for reasons I will
never know.

I spent some time gazing at the patient’s face – it was delicate
and quite beautiful, with flowing white hair framing fair, soft skin. I wondered what she was like when she was
herself, if she had a gentle disposition, or a fiery wit. I wondered if she had loved her husband, and
if she had had a happy life… I wondered why her daughter was clinging to her,
barely able to leave her for bathroom breaks.

The situation continued for a few weeks – I was a medical
student, and wrote some very bland and unenlightening notes about the patient
each day, describing her unchanging condition.
I felt sad as I watched the daughter slowly come to realize that her mom
was already gone.

One day the daughter looked at me and said, “I think I’ll go
out for a bite.” I smiled, knowing that
this was a turning point for her, and gave her a hug. “I’ll watch her for you,” I said.

As it happened, the patient was on the “house service” –
assigned to the teaching attending of the month. She didn’t have her own doctor, so she was
followed by a team of rotating residents and attendings. The new team started this day, and were
somewhat unfamiliar with her case. I
dutifully updated them on the history and events over the past few weeks.

As I stood there with the team, rounding on the patient –
they noted that her lungs were becoming harder and harder to ventilate. ARDS,” they said. “She’s going to code any time now.”

And then the unthinkable happened. The new attending, who was a bit of a cowboy,
said “let’s just end this madness. Turn
off the ventilator, it’s done.” The
residents looked at one another – one protested, “I don’t think we should do

“She’s already gone – look at her! Her oxygen is dropping, she has no pupillary reflexes,
she’s on maximum pressors…”

“But wait,” I said, “Her daughter would want to be here.”

“It’s better for her not to have to go through this,” he
said. And he turned off the machine.

I gasped. “What will
we tell her daughter when she comes back from lunch?”

Annoyed by my persistence he snapped, “Tell her she coded
when she was out.”

Thirty minutes later the daughter came back to the ICU. As she walked towards her mom’s bed, the
residents scattered. Frightened, I
approached her. She could see from the
look on my face that something bad had happened.

“She’s gone,” I stumbled… “it just happened after you left.”

She looked at me as if I had convicted her of the crime of
abandonment. At that moment, her
greatest fear of leaving her mom’s side had come true – she wasn’t with her
when she died. She ran into the room,
saw that the machines were off and all was quiet. She fell to the floor and screamed.

That scream still haunts me to this day.

This post originally appeared on Dr. Val’s blog at

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