Top 5 Ways Hollywood Medicine Fails

I realize that all of Hollywood is fake. And that creative license exists to further the storyline. But I'm pretty sure the "medical consultants" on all major TV shows and movies are from "The Doctors" and don't actually know what they are doing. Or else everyone ignores them. Here are the biggest offenders.  

1.      The biggest flub no matter who you talk to: We don’t shock asystole.

 Nearly every code depicted on TV involves a patient suddenly flat-lining (that dramatic long beep where there is no heart beat, also known in medical speak as “asystole”) and someone yelling “clear!” just prior to the body dramatically jumping off the bed. So you all know, patients rarely just flat-line. When you start circling the drain, adrenaline kicks in and your heart rate speeds up to try to match the demands of infection, injury, stress, what-have-you. The heart tries its best to keep up, its internal pacemaker keeping things going even when the rest of the body is shutting down. Sometimes it works so hard and fast that it can’t beat in rhythm anymore, a condition known as ventricular fibrillation (or V fib).

This is very scary

If that word sounds familiar, it’s because those infamous paddles belong to a device called a de-FIBRILLATOR. Meaning “to stop fibrillation”. In other words the electricity stops that crazy rhythm and allows the heart to restart its own pacemaker. Guys, the paddles STOP THE HEART. Which makes no sense if the heart is already stopped. So shocking asystole is just bad medicine, and every one who’s ever taken an advanced life-support class knows it. Even the automatic defibrillator machines know that. If there is no heart beat, we instead make the heart beat by doing chest compressions and trying to restart it with epinephrine. Which I guess is just not as dramatic as “CLEAR!” But really, how hard would it be to put V fib on that monitor instead of asystole. Seriously.

2.      Medicine is boring. I realize it wouldn’t make for the most compelling story lines, but can we talk for a second about how much of my shifts are spent typing notes, putting in orders, reviewing results, or waiting on hold for a consultant? They’ve done studies about how much of a doctor’s day is actually spent in patient care, and it’s not much. Besides that, most of the cases are routine things like telling parents that their kid’s cough will go away on its own, or telling that adult patient (again) to take their blood pressure medicine. Fascinating, I know. Believe me, I know. So sure, glam it up, script writers, but at least on cop shows they talk about all the paperwork and leg work leading up to the dramatic show-stealing chase scene/shoot-out. Yes, that one helicopter flight to the ICU is what we talk about all week, but it’s a small percentage of what I actually do, and the paperwork from it takes almost more time than the case itself.

3.      Pen tracheostomies aren’t the norm. Speaking of over-dramatizing, I just want to make sure you all know that when someone drops dead in a restaurant/subway station/playground/their kitchen, doctors (especially medical examiners) do not come out of the woodwork to put in tracheostomies or remove bullets or perform emergency surgery with a bottle of vodka and a pocket knife. 80% of the job is having the right tools, which does not include a ball-point pen ever. We all still call 911, and then start CPR. The end.

Never gonna happen

4.      One doctor doesn’t do everything. “House” made it standard, but every show is guilty of expanding the lead character’s expertise to a convenient, but unrealistic scope. We aren’t usually the ones drawing blood, giving meds, hooking up the ventilator, running the CT scanner, and doing surgery. In fact, most of us don’t do any of those things. Medicine is a team affair, and yes, that would involve paying a lot of extras, or having the docs do the more mundane parts of their job on-screen (see #2), so I understand why Hollywood does it. Just don’t expect your doctor to.

5.      Michelle would like to add an honorable mention regarding TV pharmacists: When asked “Do you know what fentanyl is?” The correct answer is not “oh, synthetic heroin?” Everyone knows what fentanyl is.

Fighting the good fight

Had a dream last night that I lost it on the wiffleball court. Lost. It. My team was short on players, the other team kept finding holes in our defense (in fact, I don’t remember us even batting; the Mercy Rule must not exist in dreams), and I dropped three fly balls. I screamed about the teams being stacked, wiffleball being stupid, and other such nonsense, and then stormed out.

I woke up grateful that I didn’t have to go to confession for such shameful behavior. But not surprised. Because I get that worked up playing recreational sports. Or pretty much anything else. I don’t know if it has to do with being the oldest, or a twin, or Type A, or some mutant combination of the three, but I hate losing.
I could try to dance around it, saying that I’m passionate, or dedicated, or that I see things through. But really I’m just competitive. I want to be the best. I want to win.

It’s almost embarrassing to be honest. Sometimes I’d rather just be the person who didn’t care, who was happy just to play, who laughed off mistakes. And while I know it’s good for me to be humbled, I still hate it. But here’s the good news: God is always victorious, and He’s on my side.

Romans 8 reminds us that we “conquer overwhelmingly” in Christ. “If God is for us, who can be against us?” We are on the winning side. Raise the banners, take a bow. God made me just the way I am, competitiveness and all, because He made me to conquer. So it shouldn’t matter that I drop a pass in football (at least it shouldn’t ruin my day) or get yelled at in the OR during an anesthesia day because I didn’t intubate on the first try (I can’t be the best at everything. Dang it!). Because those are just little battles in a bigger war, which we have already won. So I continue trying to funnel this passion towards greater goals, to humbly accept the losses, and to let the victories be His.

A doctor's tools

I like to think of myself as a minimalist when it comes to running tests and ordering medications in the urgent care. The nurses love it. My mother hates it. “You mean all you do is give them Motrin and a popsicle? That’s it?????” Yes, mom, that’s it. That’s all they need. Most pediatric disease is self-limited, either caused by a virus, or idiopathic (that wonderful term for “we don’t know what causes it”). Most pediatric injuries heal without major intervention. And so running a bunch of expensive, sometimes invasive tests that will most likely be normal seems like a waste in every sense of the word.

Plus, there’s a reason I went to 4 years of extra school and 3 years of indentured servitude residency. It’s called making a clinical diagnosis. You know, what doctors used to have to do for every patient, based on a good history and a thorough exam. They had to know how different heart murmurs sounded, because there was no same-day echocardiogram. They had to learn the signs of heart failure, because measuring brain natriuretic peptide hadn’t been discovered yet. And yes, they had to do a rectal exam on patients instead of getting xrays to diagnose constipation (which is still a more effective diagnostic tool, by the way). Call me crazy, but I like being a clinician instead of merely an interpreter of lab results and imaging. I pride myself on it most of the time. I spend a lot of time convincing parents that it’s a better way to go.

But if you want to make me doubt my clinical skills, if you want me to long for the ability to check a quick BMP or grab a chest x-ray, frankly, if you want to make me feel helpless, then take it all away. Put me in a teepee on the side of a mountain trying to tease out post-surgical abdominal pain in a teenage girl. Or on the phone with a worried friend who doesn’t want to make an unnecessary ER visit for her child. Or on the flag football field when someone goes down with a “pop” in one of his joints. My calm reassuring voice becomes laden with doubt, and I forget all of my training. Or at least that’s how it feels. At least for a moment. Then reason kicks in and I start to work through the problem, ruling badness in or out, looking for red flags, gathering as much information as I can.

The few physicians in my Wilderness First Responder course were sick of being outside the hospital, without any of our normal comforting resources (labs, radiology, even monitors) and not knowing what to do. We all needed a reminder that we are, in fact, clinicians first. We can use our eyes, our hands, and our brains instead of machines. I try to remind students of this when they rotate through the urgent care. It’s what I try to practice on a daily basis, even when I don’t have to, because it makes me a better doctor when I do have to.

And in reality, a popsicle is sometimes all the tool we need.

I hate fasting (I'm just gonna say it)

For someone who thinks about food as much as I do, fasting for Ash Wednesday and Good Friday are pretty much the highest form of emotional, mental, and physical torture that anyone could inflict. Which I think reiterates why I need it so much. Hear me out.

On a typical day, I wake up after having gone to bed the night before planning my breakfast. The important thing is a balance of sweet and savory, not too heavy on the dairy, and easy to make. I also need an adequate (but not too large) "second breakfast" if I'm working (needs to be portable and preferably quick to heat/eat because I can't use my "lunch break" on second breakfast). Don't forget the coffee, and if I went too light on the sweet side of things, breakfast dessert. As soon as I'm done with second breakfast, I'm thinking about lunch. Whether I'm in the mood for it, whether I can wait long enough, whether I'm going to have enough time to eat it, whether I remembered dessert. I try to have all the food groups (meat/protein, chocolate, fruit/vegetables, simple carbs with extra sugar, grains, dairy) and adequate portions. I usually roughly count the calories when I'm packing my lunch the night before. Then the question is whether I indulge in an afternoon beverage. If I'm at work, maybe a diet soda, green tea, or Crystal Light. If I'm off, something more in the alcoholic category. Dinner is mostly making sure I have enough protein to silence the tummy rumbles and an adequate dessert. And then I'm thinking about tomorrow's food.

Whew! I'm exhausted just writing about it. Imagine being in my head all day. There's no time to think about anything else. So when Ash Wednesday rolls around, I usually start the panic thoughts a few days in advance. What can I eat for my third meal that's bigger than the two small meals but not gluttonous? Do I have enough tuna packets for Ash Wednesday and that Friday? What's the best timing of the meals? Do I give up coffee and risk the caffeine headache or just drink it black as mild penance? How can I make sure I still have enough protein/fat so my blood sugar doesn't drop (this last one is a very real concern; remember, I'm a fainter)?

Add to that the complicating factor of working a 13-hour shift on Ash Wednesday. What if my blood sugar drops while I'm in a patient's room? What if I need to eat but can only get in half my meal before a sick patient comes in, then can I finish it later or does that count as an extra meal? Can I even stay up that many hours while fasting? (I usually try to sleep for most of these days if I can. Less awake time=less cranky time.)

And then there's the actual fasting. My tummy grumbles...everything makes me think of food...someone ordered pizza...I deserve a donut...wonder what my blood sugar is now...how many hours until lunch...does a graham cracker count as dessert...I'm weak and cold and have no energy. By the end of the day, I am not a happy person.

And all the while, my strangled soul is screaming GET A GRIP!!! I STILL got three meals. I STILL had access to clean water. I STILL had a warm bed to crawl into. I STILL get to wake up the next day and gorge on donuts. God will provide. Again and again and again. I do not need to be thinking this much about food. I need to be thinking this much about God, and what He wants me to do with all the gifts I've been given. I need to be made a little uncomfortable, because clearly my body is used to getting its own way. So, as much as I loathe fasting, this is perhaps a good reminder to me to do it more often, so that it becomes easier. Because I can't get much worse at it.

The end of suffering?

Last night I attended the 8^th Annual Great Debate in Boulder—sponsored by the Aquinas Institute for Catholic Thought—discussing physician-assisted suicide and whether it should be legalized in the United States. It proved an incredibly relevant topic given House Bill 1135 which will be brought before the Colorado legislature tomorrow. It’s also fresh in everyone’s minds given the recent celebrity of Brittany Maynard.

One thing that stood out from the debate last night was that in order to truly debate this topic, we must share a frame of reference, a vocabulary of morality and ethics, and in a sense, we have to agree on a certain worldview. For example, if you think that a person should be able to do whatever they want with their body regardless of the consequences, and that the law exists to protect that premise, then we have nothing to debate. For the rest of you, I offer the following considerations. (Sorry, they are not brief).

The basic premise of those in favor of physician-assisted suicide (PAS), reinforced by Dr. Michael Tooley’s arguments last night, seems to be that there are certain cases in which death is preferable to life, in which someone is “better off dead” (Dr. Tooley’s words), in which bringing about one’s death is a “benefit rather than a harm” (again, his words). Dr. Tooley asserted that it is up to the dying person to decide what that cutoff is. He specifically supported PAS in cases of extreme physical pain and suffering (and notably rejected it in cases of depression, temporary or sudden disability, or emotional suffering…hmmm).

This viewpoint has arisen, argued Wesley Smith (the other participant), from a shift in philosophy. Historically, from Plato to Descartes, virtue was regarded as the primary human good, primarily the virtues of knowledge and wisdom. But as advances in science gave humanity control over the natural world, Descartes directed his efforts towards “the conservation of health, which is without doubt the primary good and the foundation of all other goods of this life.” That’s a huge paradigm shift, and if you take it to its logical conclusion, humanity has a right, even an obligation to advance science in order to conserve “health”, at the expense of virtue or any other good.

Given today’s aversion to physical and emotional suffering, and our narrowed definition of health as “the absence of disease” rather than “complete physical, mental and social well-being”, it might make sense that we can and should use science to help us avoid suffering at all costs. To the extreme conclusion, as Smith put it last night, that “killing is an acceptable response to human suffering.”

I would argue that Descartes was wrong, or at least that we have warped his philosophy to an unsatisfactory conclusion. If health is the be-all-end-all, then is life really worth living? Are healthy people really the happiest, the most successful, the most virtuous? Have they truly achieved the greatest good? And if so, then what worth do unhealthy people have? It’s not a far leap to discount the disabled, the sick, the suffering as worthless. And yet, we know that’s not true. Consider Stephen Hawking, Helen Keller, FDR, who knew that they were more than their health, or lack thereof.

Yes, an appropriate response to suffering is to try to alleviate the suffering, but I think we have to realize that the absence of (especially physical) suffering is not the greatest good, to be achieved at all costs. Human life has dignity and purpose in the midst of suffering, and to let someone believe that a certain amount of suffering makes them “better off dead” is, as Smith said, abandonment.

Studies have shown that people requesting PAS primarily are afraid. Afraid of becoming a burden, afraid of losing control, of losing their dignity, afraid of not being able to do things for themselves. I think ultimately, they are afraid of losing their identity, their voice. By telling them they are better off gone, aren’t we agreeing with them? Shouldn’t we be reinforcing their worth, helping them achieve a measure of autonomy, allowing them to have a purpose, a place in a community?

This doesn’t even get into the slippery slope of deciding that there are certain populations who are “killable”, or the dangers of not treating mental illness appropriately, or the financial pressures of euthanizing over continuing medical treatment. It doesn’t get in to the dilemma of a physician who has taken an oath to “do no harm” being asked to kill. And it certainly doesn’t broach the argument that life is a gift from God and isn’t ours to take. I hope instead that by questioning the very foundation that suffering is an evil to be avoided and that killing is an acceptable answer to that suffering, that I can reach a broader audience, and help people think a little more critically about where our society is headed.

Also, please visit http://www.cocatholicconference.org/voter-voice/?vvsrc=%2fAddress to find your state representative and tell them we should not legalize physician-assisted suicide.

Tony, Tony, come around

This week I found two things I had been missing for quite a while. The first was a down glove, worn nearly all the time in the winter, a favorite--probably fallen out of my jacket pocket at some unknown location, and I never expected to see it again. I was at work on Wednesday and lo and behold, there it was, perched on the coat rack in the locker room, lonely and waiting for its owner. The second was my consecration bracelet, of which I have lost more than any one person should in a lifetime. I assumed I lost this one while shoveling one day and so was waiting for the snow to melt, confident that I would find it eventually, but impatient for that day to come. And so for this I implored St. Anthony, patron of lost items, with a confidence that I couldn't explain. I found the bracelet two days ago, while loading a piece of furniture into Michelle's trunk (long story) and there is was next to the ice scraper and the washer fluid. Tony comes through again!

Devotion to St. Anthony, especially in relation to lost items, has been a Catholic practice for many years. It is believed to have arisen from an incident in the saint's life, where he prayed for the return of a psalter (book of Psalms) that had been stolen, and the thief was moved to bring it back. Since learning about this devotion as a teenage, the words "Tony, Tony, come around, something's lost and can't be found" have crossed my despairing lips many times. In some ways, I hesitate to put faith in his intercession, because is it really any different than the superstitions we are to avoid? And yet, he has never, never failed to lead me to the lost item (except for the previous 4 or so consecration bracelets), so I also hesitate to abandon the practice.

This most recent time, when my consecration bracelet once again went missing, I immediately called up St. Anthony, and felt a peace in my heart that he would answer. I sensed that God wanted me to trust Him, wanted me to find it, and wanted me to delight in His help. And that I think is the distinction. Between superstition and intercession. God delights in us, and wants to show us His delight. I feel this every time I see a beautiful sunset, whenever a white butterfly joins me on a hike (it means Grandma is with me), and every time one of my obscure prayers is answered in an unexpected way. And I think He delights in showing me that He can surprise me in the little things.

Several weeks ago, Michelle had lost a favorite ring and had invoked St. Anthony's help. A few days later, I found the ring in a bowl of grapes in the fridge; it had come off while she was washing them. She was ecstatic. Delighted. Just as I was when I found my glove. And my ring. I smiled at God: "You've done it again," I thought. Just as someone leaves a love note, God wants to show us that we are always on His mind. And that the saints are a powerful aid for all things, great and small.

So I will continue to trust in St. Anthony's intercession. Not because I am superstitious, but because I believe in God. He can choose to answer either way, and it doesn't change His power or His love for me. An item that stays lost doesn't mean I didn't pray hard enough or the right way; just that it stays lost. God still is. And He still delights in me.

I kind of want to post this everywhere

I know that Urgent Care is easy. And the hours are better. And you’re busy. But there are just some things that shouldn’t be seen at Urgent Care. To avoid the frustration of multiple trips, waiting too long, leaving with no answers, or being judged based on your chief complaint (it happens; I’m not proud of it, but at least I’m honest), try to follow these rules.

1)      We do not have unlimited access to specialists, nor will the specialists see you sooner if you are in the Urgent Care. We get countless walk-ins and even referrals from doctors wanting their patients to have an echocardiogram or EEG, see the pediatric dentist, or get in sooner with their rheumatologist. It’s not going to happen. If it’s truly emergent, you may be admitted at our main campus and see those specialists within 24 hours, who will then decide on any workup/treatment. Otherwise, we have to go through the same channels your pediatrician does to get to the specialists, and the vast majority of the time, we are only consulting by phone, often with a resident, fellow, or mid-level provider. The end result is usually adding you to their growing appointment list, often months out. If you want a specialist, have your doctor call them instead.

2)      Please don’t come in with 6 months of chronic symptoms without seeing your regular doctor first. If you’ve had something going on for more than a few weeks and haven’t been able to solve the problem with Dr. Google or with multiple trips to other ERs, chances are it won’t be a quick fix for us either. Our job is to rule out bad things and get you the right follow up, often with your regular doctor. Plus, if we start a lab workup or want to order tests, your doctor won’t always be able to follow up on the results (and chances are we won’t either, since many of the labs and imaging studies come back once our shift is over). Additionally, if you don’t get better in two days and decide to come back, you will be seen by someone different, who will have no idea how you looked the first time, may have a totally different approach, or may disagree with what has already been done. It’s a lot easier to solve long-term issues with a long-term plan—namely, your own doctor who can see you through the illness and follow up on what they recommend.

3)      We are an URGENT care. We are not an “I just had a quick question” or “I didn’t want to make an appointment with his doctor” care. The following are all real complaints that have come in to our Urgent Care or ERs—ear pain for 20 minutes (no meds given at home), band-aid stuck to leg, need a refill on Prevacid (which is now over the counter, by the way), the child felt warm, grandma said he needed to be seen, was exposed to someone with a sore throat but doesn’t have any symptoms. There are nurse lines for these sorts of things. We are always happy to offer reassurance, but please don’t expect me to rush in when I have other rooms filled with asthmatics, broken bones, migraines, seizures, pneumonia, partially amputated fingers, or other things more…urgent. It’s always the people who don’t really need to be there that balk at the wait times. Imagine waiting until your pediatrician’s office opened. In two whole hours.