Hmmm...

I'm a little confused. Let me see if I have this straight.....

* If you grow up in Hawaii, raised by a single Mom and your grandparents, you're "exotic, different " and not a real American.

* Grow up in Alaska eating mooseburgers , a quintessential American story.

* If your name is Barack you're a radical, unpatriotic Muslim.

* Name your kids Willow, Trig and Track, you're a maverick.

* Graduate near the top of you class from Harvard Law School and you are an elitist who's not a real American and certainly not qualified to be President of the U.S.

* Attend 5 different small colleges before graduating or finish close to last in your class at the Naval Academy , you're well grounded and the most qualified to hold the two highest offices in the U.S.

* If you spend 3 years as a community organizer, become the first black President of the Harvard Law Review, create a voter registration drive that registers 150,000 new voters, spend 12 years as a Constitutional Law professor, spend 8 years as a State Senator representing a district with over 750,000 people, become chairman of the state Senate's Health and Human Services committee, spend 4 years in the United States Senate representing a state of 13 million people while sponsoring 131 bills and serving on the Foreign Affairs, Environment and Public Works and Veteran's Affairs committees, you don't have any real leadership experience.

* If your total resume is: local weather girl, 4 years on the city council and 6 years as the mayor of a town with less than 7,000 people, 20 months as the governor of a state with only 650,000 people, then you're qualified to become the country's second highest ranking executive.

* If you have been married to the same woman for 19 years while raising 2 beautiful daughters, all within Protestant churches, you're not a real Christian.

* If you cheated on your first wife with a rich heiress, and left your disfigured wife and married the heiress the next month, you're a maverick and a someone to be looked up to as promoting Christian values.

* If you teach teach children about sexual predators, you are irresponsible and eroding the fiber of society but if while Mayor of your small town, you charge rape victims for rape kits you are to be applauded for your leadership.

* If, while governor, you staunchly advocate abstinence only, with no other option in sex education in your state's school system while your unwed teen daughter ends up pregnant, you're very responsible.

* If your wife is a Harvard graduate lawyer who gave up a position in a prestigious law firm to work for the betterment of her inner city community, then gave that up to raise a family, your family's values don't represent America's ; however if you can't remember how many houses you own, your wife is one of the richest people in America who inherited her money and wears dresses every day that cost several hundred thousand dollars, the two of you have more in common with and can relate better to "real" Americans than the snooty Harvard Law graduates who paid their own way through college and law school. *

If you're husband is nicknamed "First Dude", with at least one DWI conviction and no college education, who didn't register to vote until age 25 and once was a member of a group that hates America and advocated the secession of Alaska from the USA, your family is extremely admirable.

* If you repeatedly lie about your own record and that of your opponent while your opponent refuses to make up lies about you, you're a maverick who is to be admired while your opponent is weird, out of touch elitist.

'She is like me'

Women who say to themselves, 'I like Palin, she is like me', need to ask themselves: do you think you should be the vice president, or the president of the free world, and why?'

Mike Huckabee with Longer Hair

Sarah Palin is Mike Huckabee with longer hair. If you like the stances of Mike Huckabee, vote for Sarah Palin. Since the Repubs wont lets her off the hook long enough to say anything substantial, lets get a REMINDER of where this Huckabee doppelganger stands for. Keep in mind, women, this person could be the PRESIDENT OF THE UNITED STATES. If you do not believe in evolution, vote for Sarah Palin et al., because she does not believe in evolution either. She also does not believe in global warming. She believes the Iraq war is ordained by God. She does not believe in reproductive rights. She does not believe in equal pay for women. She said nothing about the number one concern of Americans: the economy. If McCain dies, and he realistically could, this is the future President. Mike Huckabee with longer hair.

You will not hear any of these in a replay of her adolescent acceptance speech, which basically talked about energy for 2 minutes and spent the other 30 minutes making fun of Obama and Biden. She apparently never got out of high school. She is still running for beauty queen of Wasalia by making fun of the competition’s hair, or job, or wife. The Republicans have no issues to stand on, so they are going for character assassination and gossipy one liners. Do not be fooled again. This is culture war 101. Women know better than this. Seriously. Stop dividing people based on culture choices. It is not less obvious because you are using a high heel instead of a wedge.

Furthermore, I am disappointed by her reliance on mockery. This is the sign of a weak person with no real ideas to offer. My mama, Audrey Hope Monti, also has 5 children, and gave me one of the wisest pieces of advice I have ever heard. We were driving along in the back seat of our little Subaru, coming home from KinderCare day care center, after my mom had been at work all day as a high school teacher. We were bickering at each other. She pulled the car over, stopped dead on the side of the road and said, ‘There are enough people in the world to make fun of you. I do not know why you have to make fun of each other.” That is a working woman’s wisdom. Not to insult people and then do high fives over the margarita blender in the kitchen. This country needs more grace than that, more recognition that we are in this together. She is a blatant dive back to Bush politics.

In the meantime, here are five questions to ask Palin, if she is ever allowed off the leash:

1) Do you believe in equal pay for equal work for women?
2) Do you believe God has ordained the Iraq war?
3) Do you believe in evolution?
4) What do you think causes poverty?
5) Who do you think are America’s top allies, and why?

O - HI - O

Ah, election season in Ohio. I watched the 2004 primaries from overseas and tried to answer my Spanish friends' questions about America's political leanings: "But how could people possibly re-elect Bush?" I told them they had never been to Ohio.

The Economist has started its series on swing states with Ohio. It only took three paragraphs for the infamous I-71 billboards to make their appearance:

In the Cup-o-Jo Cafe in Columbus, the state capital, 20-somethings sit around eating vegetarian food and talking about how much Mr Obama inspires them to hope for a better world. Out in the rural areas the signs on the road tell a different story—“Hell is real,” reads one, and then, a few miles later, “Repent!”.

It's unclear what the presence of fire and brimstone on highway billboards means for the 2008 elections - we can revisit Issue 1 some other time. Here, The Economist does a good job of capturing in a short article both the usual issues (what do the Ohio voters care about? is Obama too "coastal elite" for the state?) and the more interesting ones at the present moment (changes in both parties' strategies since 2004, challenges for both).

I think The Economist has actually used the word "elite" in the promotional material it sends to my house from time to time, so I find it the whole discussion of Obama's elitism a bit ironic. Any magazine which runs the following sentence should probably not be debating whether a public figure is perceived as too "airy-fairy" for office:

In 2004 the Democrats argued, with some evidence, that Ken Blackwell, the staunchly conservative secretary of state, was not overzealous in ensuring that all Democrats could exercise their right to vote.

Then again, The Economist isn't trying to get elected in Ohio this fall.

* * * * * * * * * * * * * *

Full disclosure: I should admit that I love The Economist not just because of its use of hard data and balanced reporting but also because of its writing.

Is he WHAT?

As they say in the vernacular, I got called out the other day – by my roommate Jenn, of course, who is particularly good at detecting inconsistencies in people's behavior. We were talking about homophobia, and I was relating a recent incident which had disgusted me, in which someone had said something I found offensive and medieval.

I related the story. I was on call at the hospital and admitting a man with acute kidney failure. He was sick: emaciated, with awful radiation burns from a bout with cancer a few years ago and lingering weakness from a mass in his brain. We weren’t sure what the mass was, but it was undoubtedly related to his AIDS. His nurse and I worked together to get his vital signs, listen to his lungs, make him comfortable in bed. I was impressed by how gentle she was as she turned and lifted him – I followed her lead. As I was writing his admission orders – IV fluids, cream to his burns thrice daily – his nurse joined me again.

“Is he gay?” she asked, her voice rising in pitch as she drew out the last word. I was shocked: was she serious? Did she really care?

“So what did you say?” Jenn asked me.

I had tried to remain neutral. “I really don’t know,” I’d said in what I hoped was an irritated voice. I was more than irritated: I was shocked – this was, in my experience, something out of bad TV. This was morbid curiosity, plain and simple, her brush with the exotic, with the other half, with those people.

“You missed an opportunity,” Jenn observed pragmatically. What I should have said was, “Why do you care?” or “Why does it matter?”

I should have told her that his sexual orientation was immaterial. I could have gone a step further and said that the way he acquired HIV – was this why she was asking about his sexuality? – was irrelevant to his kidney shutdown, that he was very sick right now and what mattered was that we treat him, not that we probe into his personal life.

Instead I said nothing. My approach was completely passive-aggressive: I hoped my irritated tone would convey some of my disapproval. But really, was a nurse going to be surprised by some doctor-in-training being snippy? Probably not. People give nurses crap for far less important things all day.

About a year ago I missed a similar opportunity. A relative of mine said, upon hearing that I wanted to move to Seattle, “Seattle is full of Asians and queers.” Verbatim, this is what he said. Again, what did I say? Nothing much. I stammered something about that not really being true, and asked if he’d ever even been to Seattle. (He had not.) What I should have said was, at a minimum, “Hey, not cool.”

Why do I remain silent in these situations? In the hospital, it was mostly shock – I was thrown off-guard by the disconnect between the tender care the nurse displayed and the callow fascination underneath. But the only reason I said nothing when it came to my family was the desire not to rock the boat, the abstract goal to All Just Get Along. I gave him a temporary free pass for being a 19-year-old boy. I repeated the story to friends, always with the parenthesis of, “Can you believe he said that?”

It’s one thing to be a card-carrying member of the HRC, but a little confrontation goes a long way sometimes. If I never speak up, then I can’t be surprised that people do say these things.

Give me a pint ... or not

This spring, I spent a month on the Hematology consult service. In theory this meant I ran around the hospital and tried to answer other people’s questions about the blood, but in practice it meant I came up with a number of questions of my own. All of them boiled down to something I’ve planned on addressing for some time: how can medicine use blood more wisely?

Not infrequently I wrote that patients’ caregivers should “transfuse as needed.” In some cases this was a passive-aggressive way of saying, “why did you call a hematology consult in the first place?” I wrote this in the charts of patients with myelodysplastic syndrome and anemia (where the bone marrow produces either too few blood cells or dysfunctional ones). I wrote it in the chart of patients with low platelets. Usually I didn’t clarify that statement – I left it up to the primary team to decide what would necessitate transfusion.

Transfuse as needed: part of the problem with the blood shortage is the liberal interpretation of that recommendation. What are the criteria for “as needed,” anyway, when it comes to transfusing blood?

There exist, of course, standards for transfusion of blood products. According to the Red Cross,

red blood cells are indicated for patients with a symptomatic deficiency of oxygen-carrying capacity or tissue hypoxia due to a decrease in circulating red cell mass. They are also indicated for exchange transfusion and red cell exchange.

If that sounds less than straightforward, the Red Cross thought so, too, and so they have attached a few numbers to help with the “decrease in red cell mass” part: a hemoglobin of greater than 10 grams per deciliter does not require transfusion, and a hemoglobin of less than 6 g/dL should be treated with transfusion (we'll say normal is 13 to 16 - a little higher than this for a man, a little lower for a woman). For platelets, the recommendations are similar: basically, use platelets if the person is bleeding and has either low numbers of platelets or adequate numbers of dysfunctional ones. The Red Cross also recommends prophylactic platelet transfusions: over 10,000 if the person is stable and not bleeding, for instance, and over 50,000 if the person is going to be undergoing an invasive procedure.

It’s the range from 6-10 where the Red Cross says to use your discretion, and it’s the range where I see transfusions whose benefit I sometimes doubt. “The lowest I’ve ever seen is a hemoglobin of one – and that person recovered,” said my attending one day as we discussed how to boost a patient’s hemoglobin before surgery. We gave her some intravenous iron, some folic acid (both required for blood-cell production) and finally a shot of erythropoietin, the hormone which stimulates the bone marrow to make more red cells. None of these things was going to have an effect before surgery, but still we wrote for them.

I got pretty used to seeing anemic patients over the course of a month, and I started to become desensitized to hemoglobins of 12, 11, 10. I wondered whether the body, too, became desensitized. Why not? We avoid dropping blood pressure too rapidly in people who routinely have higher pressures – not because it’s good to be hypertensive but because the body gets accustomed to the higher pressure. Does the body also get used to a lower hemoglobin level? An article in April’s issue of Transfusion starts to answer that question. The authors looked at both the absolute lowest concentration of hemoglobin during / after surgeries requiring cardiac bypass as well as the relative decrease in hemoglobin during or after surgery and related it to adverse outcomes. They found that the relative decrease in hemoglobin, not the absolute lowest value, was more important for outcome.

This work needs to be replicated and expanded, but, along with studies that show no difference in outcome in ICU patients transfused liberally (to a hemoglobin of 10) or restrictively (to lower values, like 7 or 8). These data are still controversial, but I believe them. Less controversial is the need to revise our blood transfusion policies such that they are consistent with both evidence from well-designed clinical trials and with the shortage of blood available for transfusion.

Later: how can we improve the system of blood donation?

Give me a pint... part one

When I was growing up, the Red Cross used to call our house on a weekly basis. They were looking for my father, who was a regular blood donor, and they always called during dinner. These calls always infuriated my father – theoretically, they were calling to remind him to donate as soon as he was eligible, but often we’d get calls nightly for the week or two after he’d already donated again. He was not hesitant in sharing his frustration with the Red Cross representative on the other end of the line: why must they call during dinner? Why were there so many delays last time he donated? Why didn’t they know he had donated last week? Eventually we were instructed to tell the Red Cross he wasn’t home and to hang up; yelling was optional.

Despite the dinner interruptions, my dad kept donating, and his example is probably why I started donating when I turned 18. I considered it an adult obligation, right up there with voting – actually, I’d donated twice by the time I voted once.

Today I donated blood for the fourth time, which is actually pretty pathetic given the number of times I could have donated by now. Yes, I’ve been turned away in the past because I was anemic, but I really don’t have a good excuse for most of the opportunities I’ve missed. The sad thing about my paltry four donations is that they make me a pretty good donor: only five percent of eligible US donors actually give blood, and thirty percent of first-time donors never give again.

These dismal statistics are why the Red Cross harassed my father.

There are three main avenues from which the blood donation crisis needs to be addressed: first, the donation system needs a massive logistical overhaul; second, the medical community needs to be both more innovative – develop blood product alternatives that work; and, third, more people need to donate[1].

I’ll start with the last reason: donating blood is altruism at its most fundamental level. You’re giving part of yourself to someone who needs it, without asking for anything in return. At the Red Cross’s donor website, the I-gave-blood-today sticker each donor gets is described as a “badge of honor” that will make the wearer special in the eyes of his or her peers. That argument is really designed to appeal more to young donors, who are looking for reasons to be cool and admired, and I doubt that it actually wins over many potential donors.

That said, I’m wearing my sticker today, for a reason that surprises me – it’s Ash Wednesday. I haven’t been a practicing Catholic (or any sort of Catholic) in years, but Ash Wednesday still makes me contemplative. Wearing ashes on my forehead would be hypocritical at this point, since to do so would be to identify with a belief system and with dogma that I don’t truly support.

In lieu of ashes, I am wearing my blood donation sticker. It’s a statement of my belief system, and I don’t think it’s any less profound than the ashes I used to wear: altruism, one pint at a time. You could call this sort of ideal atheistic altruism, or altruistic atheism, though to me that sounds like the same misguided school of cheesy alliteration that gave us “compassionate conservatism,” which is a movement I do not associate with.

The blood donation system in this country needs a massive overhaul – that is undeniable. Some things have gotten streamlined since the first time I donated six years ago –the long list of questions about sexual and travel exposures are now on a computer instead of on paper, in tiny font. Still, it takes longer than it should, and it’s entirely understandable that people are loath to take time out of a busy day to donate, especially if they are unsure how long, exactly, it will take.

The ethics of blood donation ought to transcend political ideology and religion. The Red Cross should not have to bribe donors. If you can donate your blood, you should. Bottom line.

Basics to get you started:

• You can donate once every 8 weeks
• You have to be 17 or older and over 110 pounds to donate
• Yes, there are exclusion criteria – certain medications and travel locales will rule you out (see the Red Cross site above)
  

This is the easy argument to make. Coming soon: parts two and three of Empty Barrels’ take on blood donation – what the medical community needs to do, and what can be changed about the system.

---

[1] Here again we can place some of the blame on the system – how are donors recruited and sustained?

Reason #45 to go veggie

This article, from last Sunday's New York Times, nicely articulates one of the main reasons I am a vegetarian. I stopped eating meat almost seven years ago, for the relatively adolescent reason that I just didn't like it anymore. It probably helped that two of my best friends were vegetarians - and their parents, also non-meat-eaters, were gourmet cooks.

Since then, the argument of distaste has been superseded by more refined ones: it's healthier to be vegetarian, and it's better for the environment. Plus, I don't miss meat at all - being a vegetarian is not a question of self-deprivation.

You can yell at me about not getting enough protein, how my muscles will disappear, blah, blah, blah - that's not what this post is about. For the record, I get plenty of protein, and when I don't, it's because I am eating like a typical med student (read: junk), not because I can't find meat-free protein sources.

Think about it: meat is basically processed food. Take raw fuel (soybeans, oats, wheat) and feed it to a machine which will require use of energy, water, and land before giving you a product - which itself will have to be processed again to be useful. This doesn't even take into account the waste produced by said machine. To be fair, I should probably stop eating processed meat substitutes like commercial veggie burgers and energy bars – but I find it hard to believe that these have anywhere near the environmental impact of commercial meat farming[1].

The following excerpt sums up the Times article's main argument:

Though some 800 million people on the planet now suffer from hunger or malnutrition, the majority of corn and soy grown in the world feeds cattle, pigs and chickens. This despite the inherent inefficiencies: about two to five times more grain is required to produce the same amount of calories through livestock as through direct grain consumption, according to Rosamond Naylor, an associate professor of economics at Stanford University. It is as much as 10 times more in the case of grain-fed beef in the United States.

The environmental impact of growing so much grain for animal feed is profound. Agriculture in the United States — much of which now serves the demand for meat — contributes to nearly three-quarters of all water-quality problems in the nation’s rivers and streams, according to the Environmental Protection Agency.

You can call me a yuppie bleeding-heart-liberal for this post, but I don't care: at least I'm consistent. I am always claiming to care about the environment, but in my everyday life I'm pretty wasteful (still use that car, dry my clothes in the dryer, etc).

Not eating meat is probably the single best thing I do for the environment. If you are trying to find ways to be more environmentally conscious, you might think about doing likewise. At the very least, you could stop buying your chicken breasts in styrofoam packages.

(Note: one day I could post the boring-but-valid Top Ten Reasons to go Vegetarian, or - this would be funnier - Most Ridiculous Things People Have Ever Said to Me about Eating / Not Eating Meat.)

---

[1] At some point I'll look for data on these, or on which favorite habit of the leftist youth is actually better for the environment (recycling versus vegetarianism).

Overdosed at 2.5 years

If you listen to Sharon Brownlee[1], I am what’s wrong with the American system of health care. Not me personally – I hope – but medical students in general. There are too many of us, she says. Too many future specialists, too many future generators of bills and referrals, too many people who will wind up ordering too many expensive tests.

Although Brownlee’s opening put me on the defensive, I had to admit that the crux of her argument was basically what bothers me the most about the academic medical centers where I will do most of my training: too many cooks spoil the broth.

All the time, the doctors I work with say things like, “well, I think you have X, but I’m going to refer you to Dr. So-and-so Specialist so s/he can take care of it.” Often it is unclear to me why the referral is generated: because the doc genuinely has no idea how to proceed? Because the internist thinks s/he knows what’s going on but wants to call in the specialist for CYA[2] purposes? Because the primary doctor is already running an hour late and everyone – patients, nurses, schedulers, the doc him or herself – is too flustered to take additional time to think, research, come up with a game plan? The other day a physician admitted to me that he was referring his patients to other specialists simply because they existed at our hospital. He could have taken the time to work through the other complaints, he said, but he referred instead.

We are told by our deans and mentors that we should become specialists – mostly because of money[3]. “If you want to become an internist,” I was told in the spring of my first year by a doctor whose specialty I will not disclose, “you’d better marry rich.” At the time I was actually thinking about his specialty, but after hearing similar comments from several of his colleagues, I sort of soured.

I’ve since moved on to the blood. Part of me is drawn to hematology, or hematology-oncology (read: blood, or blood and cancer), because I am an unabashed nerd. I find the blood fascinating, and I want to work in a specialty where I might be able to help people both live well and die well. But a career in heme-onc means I’ll be working at an academic medical center forever – because the field changes so fast that I think I’d get behind in private practice.

Another part of me likes the idea of running my own show as an internist. You’ve got heart problems? Diabetes? Lung problems? I’ll deal with it. I understand that I wouldn’t be able to handle everything, but I couldn’t stand being in a specialty where I would be consulted simply out of convenience.

At one of her bioethics classes, my roommate Jenn met a Belgian doctor. I don’t recall his area of practice, but he volunteered some disparaging opinions on the US system of practice. Dermatology in particular took a beating: it did not really exist as a medical specialty in Europe the way it did in the US, he said. General internists knew dermatology – and if somebody had skin cancer he or she went to the oncologist. I suspect there was some degree of exaggeration in his answer, but at its most basic level he’s entirely right. Becoming a competent doctor is all about seeing enough of the same things over and over and over. It’s an apprenticeship during which you learn the right way to treat somebody by first seeing and then treating dozens, hundreds of similar patients. If you refer all your patients with rashes to a dermatologist, you are never ever going to do a good job diagnosing and treating skin conditions. If I were practicing without the ability to refer someone to dermatology, you can bet my loans I’d get damn good at figuring out rashes.

The worst example of the too-many-cooks principle I’ve encountered was a phone conversation I overheard while sleeping in the residents’ lounge one night. I was next to the phone, and at some early hour I heard someone trudge across the room to return a page. “This is neurology,” he announced in typical medical hyperbole. There was buzz from the other end, to which he replied, “no, you want epilepsy, beeper #WXYZ.” More buzz. “I understand,” he continued in the patient-but-annoyed tone I use with small children, “but this is neurology – you want epilepsy.” I assumed that this exchange could only concern a patient having a seizure, and, half-asleep, I was indignant on the part of the buzzing person on the other end of the line. What is wrong with the system when your patient has a seizure and the neurologist is the wrong specialist to call?

---

[1] Sorry, couldn’t get the whole article since I no longer subscribe to the Atlantic, but you get the point with the first half…

[2] CYA = cover your ass. Yes, this really comes up in hospitals and doctors' offices, such that the occasional answer of a resident to an attending’s question of “why did you do that?” is, “for CYA.”

[3] Again, it is unclear to me when the money question stops being about having enough to pay back your med school loans before you retire and when it starts being about buying sports cars.