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.

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[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.)

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[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?

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[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.

Tree Update

I need to add to Anna's initial tree descriptions. Our tree does not come to a point. Its like a church without a steeple. It is Howard Roark's tree (any readers out there? Who can name it?) I think our tree might be missing some chromosomes. Or have too many. The more the merrier we say at this time in the season. I have not fed the tree since that first night we turned it into a diabetic. I bathe the leave in metformin twice a day, glipizide on days when it acts very thirsty. Who feeds a tree soda? It can make its own food. Let just bottle up some sunshine and put that in the till.

O Tannenbaum

My roommates and I got our first Christmas tree the other day, and the arguing began before we even got the tree in the car. I guess this sort of thing is bound to happen – all four of us have set notions of how Christmas ought to be celebrated, and the tree quickly became the vessel embodying all that expectation.

You could say I started it. Bundled up and squinting through the foggy windows of Jenn’s car, I was concerned, as usual, about something that was still a few steps away: what did we have to trim the tree? I had one string of lights, but no real ornaments. I was envisioning some long ribbons, classy chains of silver or gold balls, but when I suggested “tinsel” as a broader category of trimming supply, all hell broke loose. Turns out Dari hates tinsel; Alli suggested popcorn strings and was probably sorry she did.

We had wanted to cut our own tree down, but as the freezing rain continued all afternoon we opted for pre-cut, on the grounds that at least we weren’t getting a fake tree. We had scoped out the tree sales in our neighborhood, and we cruised around the eastern suburbs of Cleveland, yelling about tinsel all the way to our first stop. The first church was closed; the second looked more promising. We filed out of Jenn’s car into the parking lot, hidden under hoods and hunching our shoulders against the freezing rain.

Our options were scotch pine (the cheapest), then Douglas Fir, then another tree which we immediately disregarded because it seemed to be going for around $95. “We’re girls on a budget,” I told the Christmas tree guy, who looked dubious about our prospects of buying anything from him.

Alli wanted to know if a group of trees had been painted. (Painted?) “Yeah, those are the painted ones,” the tree guy told us grudgingly, and as soon as he admitted this, I realized it was pretty obvious – the needles were a shiny blue-green that, after having been to many Christmas tree farms as a child, I did not recognize.

“How did you know they were painted?” the tree guy’s supervisor asked, in a tone which implied that the rest of the sentence was, “and don’t tell anyone else about it, either.” (Alli’s inside information came from having gone Christmas tree shopping with her mother the weekend before.) Dari and I refused to have a painted tree in the house, but we also refused to pay $95, so we headed back to the car. Shivering, we waited with Jenn while Alli negotiated with the tree guys. Jenn was hopeful: “this is the part where she comes back with a tree for $20.” But alas - an unpainted tree for $44 was the best we were going to get, so we gave up and headed to the one place guaranteed to have a tree which would fit both our living room and our pocketbooks: Home Depot.

Home Depot had Douglas Fir, Blue Spruce, and a variety of pine which we did not further investigate because Jenn refused to have a pine in the house, for reasons she did not delineate. Personally, I have always like Douglas Fir[1], but it’s hard to go wrong with blue spruce, which is what the rest of the house wanted. I felt like Charlie Brown as we stood in the rain in the Home Depot courtyard and picked out a tree which did not quite look the six-to-eight-feet advertised by its label. It and all its neighbors were wrapped in blue plastic netting, which made Alli nervous about any defects hidden underneath. “What if we get home and it’s all scraggly?” someone wondered aloud.

We could only find a plastic stand, which led to a lot of griping about what had become of Christmas these days. (“What happened to metal stands?” I asked.) Once we had the tree in the car, though, we inhaled deeply the smell of Christmas and forgot all about the plastic stand.

On the way home a second dispute was born over the issue of nutrition: did the tree require any sort of supplement? I said no, just water, and called my father for confirmation. Dari claimed that trees needed soda (“Black or clear?” Jenn wanted to know), which we deemed preposterous.

I insisted on setting the tree up to dry in the basement. Jenn and I freed it from the plastic hair net and opened up the branches, which turned out to be a relatively painful endeavor. (Dari later told me this was the first she’d heard of drying the tree.) A few hours later we pulled it up the stairs. Five-foot blue spruces weigh more than you’d think, and we listed up the stairs, squeezing ourselves through the door and back again on our way to the living room. We released a shower of needles with every movement. Jenn held the top – and most of the tree’s weight – as I guided the trunk into the stand. I seemed to remember that there was a lot more yelling when my father and brother set up our family tree.

We tackled the lights next. The decision to use white lights was unanimous, but I also insisted on using the lights with green wire – which, along with using straight-up water to feed the tree and drying it before placing it in the stand, is in accordance with Linden Brady Christmas tree dogma[2]. Instead, my green-wired lights ran out after one loop around the base of the tree, and we had to finish with icicle lights. Taking great pains to hide as much of the white cord as possible, we sang along to WHAM! and Mariah Carey (thank you, satellite radio).

The sum total of tree trimmings was the following: half-a-dozen miniature ornaments, the largest about a cubic centimeter in volume; a stuffed animal mouse; two colored globes, sans hooks, which we balanced on the branches; a lego angel which I got in my shoe on St. Nicholas Day about 14 years ago; and two long, red shoelaces[3] which I draped like ribbon between the boughs. Halfway through the trimming Dari announced that her mother had confirmed the value of soda in tree nutrition, so we spiked the tree’s water with Sprite. “We’re making the tree diabetic,” yelled Jenn, but despite the high-sugar diet, I felt it would be hard to destroy the tree in the two weeks remaining before Christmas.

We wondered what to put on the top of the tree. A star – maybe. I vetoed an angel. Jenn suggested a blood donation bag, at which point I informed her that she could never call me a nerd again. I wasn’t sure what should go on the tree, but I felt it should embody a value of our house. (Hence no angel.) Should we put up the blue-and-yellow HRC equals sign? A toy stethoscope? A peace sign? So far the tree remains relatively unadorned, but that hasn’t detracted from the effect it’s had on the collective mood of our house. Just the sight of the lights through the window as I arrive home is enough to lift my spirits with memories of Christmases past.

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[1] My attachment probably stems from a childhood of Decembers spent listening to our cassette of Raffi Christmas songs, which included “Trimming the Wicks on Douglas Mountain.” It’s not exactly Johnny Mathis or Robert Goulet, but it’s a fine album – “Petit Papa Noel” is probably my favorite track.

[2] I say “Linden Brady” dogma because my cousins, the Summit Bradys, always used colored lights on their tree, and I can’t truthfully speak to the particulars of all the other Brady trees.

[3] If you were to investigate the tree closely, you might notice that the shoelaces say “The LaSalle Bank Chicago Marathon” in black lettering. They’re an appropriate decoration for our house; we joked about adding old sneakers – maybe they could go on top, especially since the tree sort of plateaus, rather than peaks.