Doing our part

Democratic primaries were held around the country in the past week, and Diana and I were part of the most convincing wins for Barak Obama.

I caucused here in Boise. As you may know, there aren't that many Democrats in Idaho, so to save money, there is only one caucus per county in Idaho. Two things were especially notable this year:

• Barack Obama was the first major presidential candidate to visit Idaho in over 20 years. 14000 people gathered to hear him speak at 9 am on a Sat morning (unfortunately, I was on call at the hospital).
  
• the Ada County caucus (which includes Boise), was the largest Democratic caucus in the U.S. About 8500 people showed up to wait in the cold in lines that meandered around downtown Boise.
  
• for the first time in over 20 years, each of Idaho's 44 counties held a Democratic caucus.

Inside the Ada County caucus, it was overwhelmingly for Obama. As we were waiting for the initial vote count, I looked over at the Hillary Clinton supporters and I doubted that they would have 15%. They didn't. This means that the only viable candidate in Ada County was Barak Obama. In fact, only one county in the whole state went for Hillary Clinton.

In Washington, where the caucuses were held four days later, Barack Obama also won overwhelmingly. In fact, not a single precinct in the whole state went for Hillary Clinton. So essentially, Diana and I led the two most dramatic victories for Obama.

I think what this clearly shows is how unpopular Hillary Clinton is in the rural west (possibly even the west in general), combined with how excited voters are about Obama. Still, the race isn't over and I cringe thinking about the potential role of superdelegates and the delegates in Florida and Michigan. Hopefully the race won't come down to that.

Surgery update

Today was one of the busier days I've had on surgery at the Boise VA. It started - of course - with a hernia repair, and then we had an emergency surgery for someone who had a rapidly bleeding gastric ulcer (he could have bled to death without surgery), and then we removed someone's gallbladder. Surgery can be interesting, but in general, I actually find it a little boring, at least from my perspective. Much of the time is spent figuring out what you're looking at (I assume this isn't the case for experience surgeons), and it is usually tedious and slow. Still, I'm learning useful skills: my sewing skills are rapidly improving and it's helpful to know about what cases are surgical emergencies.

In other Boise news, I did some great backcountry skiing last weekend near my parent's cabin. I continue to be spoiled by my and Diana's family. And believe it or not, Barack Obama is actually coming to Boise this Saturday.

On Obama v. Clinton

Two recent editorials on the Democratic primary address the heated race between Obama and Clinton. Check out this Nicholas Kristof article in the New York Times on experience as a quality in presidential candidates. Also worthwhile is a piece from the Wallstreet Journal editorial board about Clintonian campaign tactics.

For full disclosure, I'm an Obama supporter, and I highly recommend his book, "The Audacity of Hope" in which he discusses his take on politics and the issues facing America. He describes a post-Bush/Clinton era in which the squabbles of the past 40 years are consolidated and the issues are reconsidered and reframed. I think he would truly represent a giant leap forward in the progress of American politics, but that's just my opinion. . .

Doctoring in God's country, one surgery at at time

Here it is 2008, and I'm finally posting again, and resolving to do so with greater frequency.  Keep me to that, would you?

I've finished my Internal Medicine rotation and now I'm on my Surgery rotation at the Boise, VA  That's right, I'm living in Idaho again, while Diana remains in Seattle, bringing home the bacon, keeping the building from burning down, and dealing with the kooky owner.  

I live in the house my parents just bought but haven't moved into yet, about a 10 minute walk from the VA.  I seem to have reverted to my JVC lifestyle: no tv, no internet, no car.  I walk or run most places I need to go.  The other day I lost my cell phone and I felt like I was in the middle of a vast wilderness in the middle of downtown Boise, with no way to call anyone, no way to get anywhere useful (try to find a payphone these days), and with only my ipod to tell me what time it was.  Oh yeah, the ipod . . . I guess I'm not such a monk after all.  Did I mention that I haven't had to cook dinner since I've been here?

As for the surgery aspect of life, so far it's been good, but it's mostly an attempt not to screw up.  The key is not to touch or bump into anything non-sterile, not to get in anyone's way, not to ask dumb questions, not to not know the answers to the questions that you are asked.  I'm beginning to think that the greatest joy in the life of a surgical nurse is watching medical students make stupid mistakes in the OR, and then making wisecracks for the rest of the day.

Thus far, I've seen several hernia operations and a prostatectomy (prostate removal).  Tomorrow I'll see a below the knee amputation.  So far my role is limited to answering questions, holding/maneuvering the laparoscopic camera (the camera they put inside the body for some operations), and basic suturing.  Because there are no residents (which would NOT be the case if I were in Seattle), it's often just me, the surgeon, and the scrub nurse who are scrubbed in and participating in the surgery itself.  

I always say I'll post again soon, but I make no promises this time, despite my resolution.  Stay tuned.  

Tower Apartments

We just bought a new camera and I thought I'd try to get a picture of the tower behind the building, which is lit up for the holidays.

Sicko

After months of intending to see the movie, Diana and I finally rented it at the movie store. Like other Michael Moore films, it is entirely anectodal, too emotional to allow the viewer to actually consider the issues (without extreme amounts of guilt, anyway), and utterly aggravating. Still, you should see it.

The basic premise is that the US health care system is based on the for-profit insurance system, and for-profit insurance companies have a financial incentive to deny care. As one psychiatrist recently told me, the most cost-effective form of health care is death. This should come as no surprise, since almost by definition, capitalism is amoral ("invisible hand", anyone?).

On the other hand, hospitals and doctors have a financial incentive to provide medical care and perform medical procedures that they can get insurance companies to pay for, even if it may not be an absolute medical indication.

So the patient is caught in the middle of one system (the insurance industry), whose interest it is to deny care; and another (doctors and hospitals) whose interest it is to bill for care that will be reimbursed. Ideally, somewhere in the middle is what the best medical evidence indicates is the best medical treatment for the patient.

So far, I have not seen much of this tug-of-war. It occurs to me that this is because I have spent most of my 3rd year at public (Harborview) or federal (the VA) hospitals.

As I was watching Sicko, the idea that those responsible for paying for care would limit the care they pay for, was not foreign. The same is true at the VA, where there are numerous restrictions on what care is available to patients, for the same financial reasons. There are at least two main differences, however.

First, there are established protocols to access normally unavailable procedures or drugs. For example, I saw a patient this morning with Parkinson's disease in neurology clinic. He was on a medication called rivostigmine, which has been shown to prevent cognitive decline seen in Parkinson's (it is also one of the only drugs approved by the FDA for the treatment of Alzheimer's). This drug is not usually available to VA patients, and requires that the physician fill out special paperwork (an "extra-formulary request") to obtain the medication. Sometimes this works, and other times the established protocol for provision of these drugs makes such a request impossible, depending on the patient's circumstances. But as far as I have seen so far, drugs on this list have proven to be only marginally effective (rivostigmine shows only a 2% improvement over placebo), and I have not yet seen a situation where a restricted drug was medically necessary.

Second is the issue of accountability. Is there any recourse to the insurance company that denies treatment? I'm not sure, but I can't think of any. Is there any recourse at the VA? I'm not sure of that either, but at least there is some transparency. From my perspective as a medical student, it seems that there is at least documented logic for why certain treatments are provided at the VA, and others are not (for the record, I only know of a few of these treatments that are not provided). And at least there is some distant, democrat feedback loop to file complaints.

One final note on the VA: make no mistake, it is the most "socialized" form of medicine in the U.S. Veterans are cared for regardless of their ability to pay, and as far as I have seen, they receive excellent care. Many highly respected, extensively published physicians practice at the VA and provide care consistent with standards of evidence-based medicine. The VA also has a national medical records system, which is a massive database of patient information and outcomes data. For this reason, some very influential clinical trials have been done at the VA, and ironically, VA patients (at least here in Seattle) have access to many clinical trials and experimental treatments that are part of research protocols. Though antiquated and a bit bureaucratic at times, the VA seems to me to be on the same cutting edge as the rest of the private medical establishment.

In the end, most of you who haven't seen Sicko have probably already made up your mind about whether you will. I encourage you to see it. As Atul Gwande, a surgeon at Brigham and Women's Hospital in Boston, said in his review of the movie, "the movie brings to light nothing that the media haven’t covered extensively for years". There are no new revelations about the American health care system, but neither are there solutions. That, apparently, is left to the presidential candidates. . . .

Code Blue

Last week I participated in my first code. First a word on codes in the hospital.

Each night my team is on call, we carry code pagers, which as the name suggests, only go off when someone is coding. A code is called when a patient stops breathing, or either doesn't have a pulse or has a life-threatening arryhthmia. When the code pager goes off, there are a series of distinctive beeps, and then the operator says what kind of code it is, and where in the hospital it is happening. When we are on call overnight, our team is responsible for any code on the wards or in the ICU, which means my senior resident (who is a second year resident) is responsible for running the code. Every one on the team is supposed to have a designated role which ideally has been discussed before the pager goes off. Obviously, code pages are urgent, and when the pagers sounds, everyone goes running.

It was about 4:45 when I was awoken from sleep by the code pager. I took one second to make sure I wasn't hallucinating, and then put on my shoes as fast as I could, grabbed my scrub top, and took off out of the call rooms running toward the ICU. Unfortunately, the medical student call rooms are across the hospital from there, and after a rapid trip up the stairs, I found the ICU (running up stairs in Queen Anne definitely paid off).

It wasn't hard to find the code. The patient's room was overflowing with nurses, respiratory therapists, and numerous other people. I caught the eye of my senior resident right away, and he told me to put gloves on and break the nurse who was doing chest compressions. He told me to do them like her, but faster.

Before this, I had only done chest compressions on mannequins in CPR class. You hear that it is hard, but it doesn't really sink in until you have to do it. As I did compressions, I had no idea what was going on with the patient, nor had I ever seen him before. I focused on what I was doing and kept my ears open for further instructions. It was chaos around me. Hovering over everyone was my senior resident and a cardiology resident, managing the chaos, trying to determine why the patient is coding, and what algorithm they should be following to correct it.

Fortunately, the residents did figure it out, the patient was given some medications (this is another story), and he soon had a pulse again. I no longer had to do compressions, which was good because I was exhausted. From start to finish, the code took about 25 minutes (I did compressions for only a couple minutes) and as far as I know, the patient stabilized and recovered.

It was my first code, and though it ended well, it is a traumatic, even brutal, experience for the patient. It's hard to convey the chaos of the code, with the alarming sounds of the monitors, the resident giving orders, the nurses giving meds, the anesthesiologist having a hard time intubating the patient, the surgery resident seemingly stabbing blindly into the patient's groin with a giant needle, and the patient's unconscious body absorbing chest compressions and these other insults. Fortunately for everyone, this code ended well. It's frightening to think that in a couple years, I'll be a resident in the hospital overnight, responsible for running a code like that one. It's exciting but intimidating to realize how much we're expected to learn in a short time.