As we take this blog's energy to a new project, build with us...

It's time. It's time to take the energy from this blog, which has served as the intial experimental space and the foundation for a larger project, to a bigger space. The same notorious team who put this blog together (Andru Ziwasimon and myself) and an amazing team of others (including my brother Nalin) have created the first health justice focused online community space -- titled Cure This. Here's what it's about:

For two and a half years, "Cure This" was a pipe dream shared by just a handful of us. We envisioned a grand goal: to create an online space to discuss health in its broadest sense, share personal stories, creatively make positive change, and build an online community along the way — connecting us locally, nationally, and perhaps internationally. We envisioned a humble beginning: here and now.

Cure This has now transformed into a reality, and we’re excited beyond words. We welcome it into this world with a loving, gentle nudge and an encouraging whisper in its ear. Let the beautiful journey begin.

But first, thank you to everyone who read To the Teeth -- written by Andru, myself, and guest bloggers Sri and Rahat over the past few years. This blog saw its start back in January 2003, when there weren't many health justice-oriented blogs on the internet. We poured a great amount of love and passion into the creation and maintenance of the blog. It was exciting receiving comments and emails from folks who really believed in what we were sharing. For those of you who have not perused the archives or the rest of this front page, I especially encourage you to read Andru's posts -- whether on building his innovative clinic or on pushing the edges of health justice work. They are truly inspiring pieces of writing. Come back to read them if you don't have time now -- this site will be archived indefinitely (for as long as blogger allows it to be!)

The last few months have been met with very sparse posting here on To the Teeth, as Andru and I have been involved in quite a few other projects. Andru has been building an amazing innovative clinic (which he shares stories from in this blog) and railing against the injustices of the New Mexico public health and hospitals system, in a quiet but hugely successful coalition-based people-based way. He's also been leading the Racial Disparities initiative of the National Physicians Alliance, a young organization of progressive physicians. I've been writing at my personal blog -- Los Anjalis. I've also been involved in intense training in my family medicine residency program at Harbor-UCLA (check out our resident blog), doing some international medicine, and serving on the Board of Directors of the National Physicians Alliance (check out the NPA's blog, full of energetic physicians' posts!) During this time, we were also holding secret meetings with team members on the creation of the not-so-secret-anymore Cure This project.

Now, what a way to end a blog project! The last post on this blog, entitled "Support the Bhopalis right to live", was written in March 2007, about the hunger strike that 6 community leaders undertook in Bhopal, India (read the post for more info). Satinath Sarangi, one of the bhopalis fasting, wrote a comment on the blog WHILE fasting, on the 12th day of the fast as his body was breaking down its own stores into ketones. He thanked us for spreading the message. Talk about the power of the internet to bring the day to day activities, direct actions, and strategy of health justice work to the rest of the world -- so beautiful and so humbling at the same time.

With this spirit and energy and awe, we hope you will join us at Cure This, create an account, share your own thoughts, and promote greater collaboration among various groups and individuals separated by geography, on various issues of health and health justice. because we love the internet and its ability to bolster movements. because our health (personally and collectively) is ours and nobody can take it away from us. because it's time we dreamed instead of only reacted.

Support the Bhopalis right to live.

6 strong Bhopalis are on a hunger strike right now, demanding action on 6 important areas (health care, economic rehabilitation, cleanup of toxic wastes are 3 of them) that have been neglected by Union Carbide and Dow for the last 22 years since the deadly disaster in Bhopal in 1984. Today, the world community is rallying behind the courageous community in Bhopal and the 6 hunger strikers. I sent a fax in a minute to politicians in India through the Students for Bhopal "Right to Live" campaign website, you can too. Let's call also!

From the International Campaign for Justice in Bhopal blog, a reportback on Day 9 of the hunger strike:

As the six fasters plan out the future of the 'Right to Live' campaign, the Tinshed is overflowing with supporters from all walks of life. Students from Muskan, women from Mahila Manch, teachers from Eklavya, and the passion-ridden youth from Yuva Samwad offered their support through numerous acts; some fasted in solidarity for the day, while others participated in singing which has become inevitable in the twenty-two days the survivors have occupied the tent. The headline maker of the day was the visit of Narmada Bachao Andolan activist Medha Patkar. As soon as word got out that Medha Patkar was at the Tinshed in support of the Bhopalis' dharna, the press promptly arrived and flooded her with questions and flashing cameras as phone microphones were thrust in front of her. "The gas peedit symbolise the affected... This struggle, indauntable, gives inspiration and strength to all who are fighting imperialist forces." She also said that through Sangarsh 2007, she will raise the issue with hundreds of organisations.

Along with national support, international support is starting to pressure the government from another front. The phone lines are being flooded by callers from America and the United Kingdom. More than a hundred calls a day flood the phone lines of the secretaries and personal assistants of the Chief Minister, the Collector, and the Prime Minister, to the point that they know by now that a call from America or the UK is regarding the fast. Some of the secretaries say they will convey the message to their boss, while others simply hang up. I suppose getting a hundred and fifty calls late in the night could possibly lead to immense frustration. The receptionist at the fax machine does not have it any easier. About 1500 faxes have been sent to the state government. That is fifteen hundred more people all over the world who will not stop until the government ceases its insensitive idiocy and for once, does what it is supposed to do. Because twenty-two years of negligence is much too long.

cross-posted at Los Anjalis

There's always the option of self-diagnosing...

From yesterday's Dilbert (click on the cartoon for an enlarged, easier-to-read view):

more Dilbert cartoons here.

"Medicine is a noble profession. You render it shameful."

...or "the tale of an unlucky appendix, at the hands of the daughters of charity, in the city of angels."

Robert Issai
President and CEO
Daughters of Charity Health System
26000 Altamont Rd.
Los Altos Hills, CA 94022-4317

Dear Mr. Issai:

I recently suffered from appendicitis, and was admitted to the emergency room at Saint Vincent Medical Center in Los Angeles on November 10 of last year. I underwent an appendectomy and was released from the hospital on the morning of November 12. I have no complaints about the quality of my care. My surgeon, Dr. Charles Hunter, was excellent, and with very few exceptions all of my encounters with hospital staff were as pleasant as they could be under the circumstances. But I received a profound and unpleasant shock shortly after returning home. The bill arrive, account number XXXX, if you're curious.

I was charged -- am being charged, I should say, as I have not yet paid -- $15,833 for the care I received during the 40-odd hours I spent at Saint Vincent. I then received additional bills from the surgeon, the anesthesiologist, and the emergency room physician for their respective services. (The latter is asking for more than $800 for the approximately three minutes he spent at my side.) I am a freelance journalist, and I am fortunate enough to have health insurance at the moment. Blue Cross covered $12463 of your bill. But $3370 is still a considerable sum of money, so I telephoned the billing office and asked for an itemized account of the charges.

I hardly know where to begin. Perhaps with the $21 I was charged for each of ten 10 ml saline IV flushes. I do not know the going rate for a 500 ml bottle of saline solution at CVS, but considerably less than $105, I am sure. I was charged $80 for each of three 50 cc doses of .9% sodium chloride, a few spoonfuls of table salt, and $154 for each of twelve one-liter bags of sugar water. For my pajama pants -- of such flimsiness that I would be hard-pressed to find their equivalent at a 99-cent store -- I was charged $35. Given such absurdities, it seems hardly worth mentioning that I was charged $982 for an hour and three quarters spent unconscious on a gurney in the Recovery Room and $1768 for each night of room and board. Rents are high in Los Angeles I know, but that is nothing less than an outrage.

A few weeks later, I was doing a little research to find out where to send a friend who had broken her ankle in New Mexico and needed surgery in Los Angeles. One of your own orthopedic surgeons advised me to use another hospital. "Saint Vincent is notorious for overcharging its patients," he said. This was not news to me. Another example: my friend was charged $1.05 for a 2 ml dosage of fentanyl at the ER in Albuquerque. At Saint Vincent I was charged $71 for a 250 mcg injection of the same. Assuming a standard 50 mcg/ml concentration, you overcharged me by a factor of approximately 28. I can only congratulate you for your chutzpah.

Mr. Issei, if you were in any other line of work, no one would hesitate to call you a thief. I understand the complexities of our healthcare system better than most do, but this is inexcusable, and all the more so in an institution that masks itself with the gospel of charity. Medicine is a noble profession. You render it shameful. I am sure you have better insurance than I do. I wish you good health, and poor sleep.

Yours sincerely,

Ben Ehrenreich

Source: "Medical Larceny" by Barbara Ehrenreich, in the Huffington Post

Mr. Ehrenreich is author Barbara Ehrenreich's son. She says this about the issue:

The odd thing is that many politicians and pundits believe that the only way to control health costs is to get consumers to limit their consumption of health care - as if an appendectomy, for example, was a kind of self-indulgence. In my son's case, we have someone who is vividly aware of his health care costs, if only because he bears so much of them. His letter is not only an individual complaint but an act of good citizenship. We all need to be prepared to blow the whistle on medical larceny.

There are some interesting comments and perspectives written by readers of the post, at the link above. Imagine what kind of discourse and building and action could grow from folks around the country sharing these stories? What's your story?

(cross-posted at Los Anjalis)

-anjali

An unfinished poem... I don't know if I will ever finish it, so here it is. Not sure if it works or flows.

Sri

On AIDS in Tanzania

Something as simple as a pill in the palm of her hand

This Tanzanian woman

Sings as she breast feeds

They say it was the rain

But it was always my tears and sweat

Which brought up the maize

They said the railroads

Will bring a new day

But it was always diamonds going

with the sunset

The other way

----------------

And now she dies and is dying

-------------------

Something as simple as a pill in the palm of her hand

This Tanzanian woman

Brilliant orange head wrap

Red African mud between her toes

Any pill

Anything close to healing

She does not hold in the palm of her hand.

-----------------------

her left breast sags in

the sun.

ribs exposed

continuum with the spine of her too large wooden chair

she resembles the chair

both of them frail

twigs

ready to snap

-------------------------

a pill

something as simple as a pill in the palm of her hand

her hands scathed

rough as maize husk

she dies and is dying

her 5 month old

baby boy born at dawn

suckles at her dry left breast

he suckles ashes from her left breast

--------------------------------------------

something as simple as a pill in the palm of her hand

Who owns this pill?

What plant or human genome extract gave birth to it?

Who cut the compound, packaged

into compact cure?

In which boardroom, what lawyers patented it?

Blue suits and leather suitcases

tucking death into the space between fine print

---------

Who keeps the cash?

Which markets rose while she fell?

Which corporate graph will track her demise?

Who will clench their fists one over the other as she opens her hand?

--------------------------

This Tanzanian woman

Her baby boy born at dawn

Who will began to ask for a moratorium on their death penalty?

Something as simple

as a pill in the palm of her hand

--------------------------

Who will join this standing up?

A reach to claim the pill

demand the pill

And place it in her hand

Something as simple

And good

As healing

A pill in the palm of her hand

Sri

2/9/07

We did it! Our clinic has a new home.

I've been silent the past two months. Activity at the clinic has boomed and during the month of December we began moving the clinic to our new building. I probably put in 16 hour days for the past month working with 30-40 other volunteers doing tiling, bamboo flooring, wall painting, moving massively heavy x-ray machines and hydraulic exam tables, and setting up a clinic. There were so many wonderful moments I could never find a way to express them all but i'll share a few because it was such an inspiring and unbelievable process.

I have to give thanks to the building owners and occupants who let us "push them out" early so that we could get our remodeling work done!

And thanks to the core volunteers, members of the Topahkal Health Collaborative who put in weeks of backbreaking work. We know every grout line, every groove of the bamboo flooring, every layer of paint on the walls, every wrong cut on the 800 pound doors. If i never had to cut another 36inch heavy wood door again, i'd be a happy man.

Thanks to the christmas eve crew of tile volunteers who took a bunch of beautiful donated tile, 5 different kinds, that together barely covered the last room needing tiling, and made a gorgeous design to welcome out patients into the clinic. it converted the place from a beautiful clinic, to the "beverly hillbillies" clinic. we were all so exahusted by that time that we would never have been able to finish the remodel work before opening without their generous help.

thanks to the children who screwed down backerboard, but the fridge doors on and cut tile on the wetsaw.

thanks to the detention kids who came by and helped us move thousands of pounds of heavy equipment from the casita clinic to our new space.

thanks to the hardy souls who showed up after a foot of snow fell and we still had two solid days of work left.

thanks to the lock and key guy who came and changed our locks and then told us that he wanted to do it for free to honor the work we are doing in the community.

thanks to our patients for putting up with our dirty, calloused hands, our dusty clothes, our muddy parking lot, our scattered brains. even though we were closed, patients kept showing up with urgent issues and we would just find a quiet spot, sort thru boxes to find the gauze and take care of business.

thanks to the carpenter who worked thru snow and ice to put in our new windows. because of the snow the windows were delayed and arrived the day before we were to open. He got two of the windows in before we opened and the third went in as patients began to show up yesterday.

thanks to the health worker who is now answering our phone for us in the mornings.

thanks to our work study students and pre-medical volunteers who put in tons of hours, learning skills they never thought would be a part of taking care of patients. it was great seeing students learn to drill, cut backerboard, tile, paint, put in wood flooring. :>

thanks to my family and friends and the supporters of the Kalpulli Izkalli for all the financial and material donations that helped us pay for the cost of the move.

We opened yesterday and saw 20 patients on our first day. our patients all like the new space even though it's still a bit rough around the edges and two cars got stuck in the snow/ice.

Personally, i LOVE the new clinic building. it is 2200 square feet of "homey hassle-free medicine." i no longer have to move my desk out of the way to open the closet to get the ultrasound machine out to do an exam for a pregnant patient! we also no longer have to store our medical supplies on shelving in the shower! :> yehaw! we now have a triage area, a gynecology room, three exam rooms, an x-ray/ultrasound room, two traditional medicine rooms, a kitchen and three bathrooms! and we have a huge parking lot and tons of space for gardening outside, once the snow melts.

so many blessings, so much love and kindness and good work done. i am pleasantly exhausted and beginning to physically recover from the work.

i wish joy and peace to each person on your journey for a better world.

sincerely,

andru

Even better, i'm heading there with 10 friends -- all resident physicians (and one faculty member) from the Harbor-UCLA Family Medicine residency program. We're going to be doing two weeks of mobile medical clinic work in the rural town of Shirati, Tanzania -- a town that borders Lake Victoria in the northwest part of the country. After the two weeks of work, a few of us will be staying on to do some travelling -- Zanzibar, the Serengeti, Dar es Salaam, decide as we go, etc. And in the last few days of our trip, we head to Nairobi for the activist orgy otherwise known as the World Social Forum!

One of the residents in our program spearheaded this trip to Tanzania, as is becoming a nice tradition in our residency program. This past year, a few residents and faculty members worked in a rural hospital in Chiapas, Mexico for two weeks. And last year, residents organized a trip to Sri Lanka and a trip to Pakistan to assist with relief efforts post-tsunami and post-earthquake.

I'm stoked about this trip, although i'm frantically trying to get things organized for it. i'm hoping to post about it in the next few days before I leave, and then in the infrequent times that I'll have internet access in Tanzania and Kenya I'll try to post here. But the place to check out the posts from several of the residents is our unique Harbor-UCLA Family Medicine Residency blog!

Kenya feel me now?

(cross-posted at Los Anjalis)

Labels: kenya, residency, tanzania

Did you put something in your ear?

Yesterday I worked a long 12 hour shift (yes, there are short 12 hour shifts and long 12 hour shifts) in the pediatrics emergency room at a county hospital as part of my pediatrics experience during my family medicine residency training. I didn't end up leaving the hospital until a while after my shift ended because I wanted to tie up loose ends and make sure two patients who were being admitted to the hospital wards had their studies (imaging, blood studies) all tucked away. I was exhausted.

But all is still OK. Why? Because my ER shift was fun. FUN. The kids are the cutest. There are traumas and emergencies that bring us joy (in stabilizing/curing) and sadness (gun shot wounds and freak accidents in kids are the worst). But some of the funniest interactions occur with the less acutely sick patients.

For example, a 10 year old girl with headaches for a week straight gives me more information on these pains -- how long they last, what they're exacerbated by, how they affect her at school, and i rule out the most dangerous causes of headaches with a number of questions. But the first thing she says to me when I walk into the room, introduce myself, and ask her what's bothering her is -- "I've been having headaches for a week and I just cannot afford it." I had to stop myself from busting out laughing during the rest of my interaction with her.

And a 3 year old boy who we think has whooping cough (pertussis) because of his extended coughing pattern (and related symptoms) also had some trauma to his left ear, and there's a little bit of dried blood in the ear canal, but no damage to the eardrum. Definitely looks like he tried to put something in his ear. But he vehemently denies it, when I ask nicely, and when mom asks nicely. Then the attending doctor (the senior doctor running the ER) comes to see the patient again with me, kneels down in front of him and says in a really sweet voice, "Hi I'm [insert male first name here]. How are you? Did you put something in your ear?"

The child nods his head side to side, motioning "No."

The doctor whispers, "I won't tell anyone if you put something in your ear, you won't get hurt." And then the doctor repeats, in a cute voice, "Did you put something in your ear?"

and the child nods his head up and down and smiles the cutest smile EVER.

Why do we clamp or cut the cord at birth?

If you are a medical student, resident, doctor or L and D nurse, have you ever wondered why we are so quick to cut the cord? Is there evidence or proof or a serious reason or any thinking at all behind this nationwide medical tradition?

I was told during medical school that we cut the cord to prevent the baby from getting too much blood and being iron overloaded... Made perfect sense at the time and I never questioned it again until about two years ago when it dawned on me that there might actually be benefits to NOT CUTTING the cord immediately at birth. I'm not particularly thoughtful or insightful, I just hang out with midwives and doulas and one is bound to get some common sense knocked into your head if you are quiet long enough to hear a thought outside of your own narrow training.

Is there any evidence that not cutting is harmful? Not that i've ever seen and i've asked alot of experts as well. There is a new research article out that demonstrates delayed clamping of the cord (3 minutes instead of 15 seconds) can prevent neonatal anemia and only raises the hematocrit within normal range. No dangers at 3 minutes. According to the article, this is a highly controversial topic. What amazed me is not that it is controversial, but that no doctors seem to even talk about it. It's not controversial, it's another medical taboo. These guys probably did a lit search and they also say there is no research stating that it is dangerous to delay cord clamping. (http://www.pediatrics.org/cgi/content/full/117/4/e779)

I challenge medical students and residents to push the envelope on this one and question your teachers. You will learn alot about how medical opinion is formed and protected. First elicit your teachers expert opinions. "Why do we cut the cord right away? Is it harmful if we don't? What benefit is there? Is there a situation when it might not be necessary?" Then ask them to share with you the research evidence that supports this practice. And then report back here what you find.

Now take a moment, trust nature, and think about the physiology of birth. Isn't the cord how the baby "breathes" in the womb? If the baby is blue and not breathing right away (assuming the mom was relatively healthy and the cord isn't falling apart in your hands from infection or IUGR or mec staining) and there is a strong pulse in the cord, wouldn't the baby be better served being placed on mom's belly with the cord attached, receiving warmth and oxygen for a few minutes while it acclimates to the physics of it's new surroundings?

And for normal healthy babies that come out screaming, what harm is there in letting the kid transition for a few minutes while the physiology of the placenta and cord figure out it's own end moment? Why do we need to put a human touch tainted by an aggressive relationship with time into the birthing matrix?

I'm so curious why we intervene in a normal process and more curious what a comparison trial would show for blue babies who are whisked away in the first 10 seconds to intubation or blowby O2 compared to blue babies with a healthy cord pulse given a few minutes to acclimate while still attached to it's natural O2 source.

Fear will probably never let that trial happen, with the assumption that we would be placing the baby in harm's way... I'm not sure. I think it's worth a serious conversation between MD's, midwives and birth assistants. We might even have to invite the opinions of doctors, midwives and birth assistants from countries that aren't completely dependent on technology to get a more grounded and physiological perspective.

andru

Topahkal Clinic growing and moving

November 2006

We are approaching the beginning of our third year of business as a fair priced, hassle-free, primary care clinic offering holistic same-day medical services to low-income people in New Mexico. Our patients have come from as far away as Juarez, Mexico and Denver, Colorado, people referred to us by family or friends. We are seeing 20-25 patients daily, totaling about 5,000 visits each year with 1-3 hour wait times. We've collected over 95% of our fees and made the up other 5% by small and large donations from patients and friends. We started working with medical students and residents at the local public hospital and we are developing a staff of work-study students who are mostly pre-med and pre-nursing students helping us as health workers and medical assistants.

All in all, it's been an amazing two years for me. My patients have been kind, considerate, appreciative, and gentle with me when i've made mistakes. We have a diverse patient population with problems ranging from substance abuse to miscarriage to complex gynecologic issues to dermatology, wound care, chronic pain and chest pain. We've sent 5-6 patients to the Emergency Room for serious illnesses including stroke from brain cancer, subtle myocardial infarction, new diagnosis of acute leukemia, profound cholecystitis requiring a 9 hour surgery, and wolf parkinson white syndrome.

We have outgrown our little casita and have a daily whirlwind of too many cars trying to fit into too few spots.

It's definitely time to move! We searched for over 8 months to find an appropriate location and will be moving the clinic right around the corner to a building that was originally built as an urgent care in the 1980's. It was built small (but is three times larger than our little house) and abandoned by the hospital that built it for a much larger building futher down the road. Parking is GREAT. Location is GREAT. The building is kinda dumpy and constructed with no windows. i'm still wondering if that was for security or privacy or to save money.

We have a plan in place to remodel. Tile the floor, cut in windows, paint the walls, landscape, decorate, tea and footbaths. Transform the building from a windowless office to a homey, welcoming, warm, holistic clinic. That work outlines the entire month of december and probably well into the future.

We have to leave our house clinic. Our neighbors have had enough, and rightly so. The traffic is overbearing, the parking is spilling out to neighbors yards, the trash is piling up from all the sodas and bags of chips that patients eat before they come into the clinic and are told they have diabetes. Our last day in our little casita clinic is Decmber 22. We open in the new building January 3rd, 2007.

Wish us luck, this is gonna be quite a journey to get that building ready in so short a time.

andru

Shock and Awe: thoughts on the UCLA taser incident

My friend Vivek is a law student at UCLA and writes at a wonderful blog called Your Good Name. He participated in a protest organized by UCLA students, on the issue of a Persian-American student who was tasered (stunned by a stun gun with 50,000 volts) several times by community police in the university library. And he had this to say about the framing of the protest:

But after attending the protest today at UCLA, where the messaging was around public safety rather than police brutality and race, I realize that we do not have much time. We don’t have time to obfuscate, to skate over the issues that dig deep into us and threaten to rip us all apart.

If we don’t call things as they are - that Mostafa was targeted because he was a Persian male, that he was cuffed and then tazed more than four times because he was a person of color, that the UCPD’s actions have created a climate of fear for people of color all over campus, that ’safety’ as a message only means more cops and no change in accountability - then we all suffer.

We don’t have time to call things otherwise because eventually we all are going to be hit by this. And it will hurt like hell when it happens to us or to someone we love.

Amen. I agree with that. Here's to calling it like it is, for our kids' sake. Good analysis, Vivek.

Now, for some other thoughts on the tasering incident:

[1] I'm so impressed by the actions of the student who was tasered in this incident. I mean, he fell to the ground, limp (in true civil nonviolent disobedience style) when the police wouldn't let go of him. He called the police out on the Patriot Act while they had their tasers pointed at him. He repeatedly explained to the police that he wasn't attacking them. Do you know what a taser does to you? It's 50,000 volts of stun gun. Makes you lose bowel and bladder control in many cases and literally stuns you into paralysis for a few minutes. And all that time, between the taser shots, Mostafa Tabatabainejad was telling the policemen like it was. I don't think I could have been so courageous.

[2] Don't know what i'm talking about? Haven't checked out the YouTube video yet that was shot on a cell phone videocamera? Indymedia has a link to the video here (disturbing) -- [link]. Upon seeing this video, I was shocked (no pun intended) by how brazen the police were, KNOWING very well they had an good sized audience of undergraduate student witnesses (and maybe they even saw the cell phones pointing at them, shooting video). I mean, how do you do this with an audience? How do you not think twice about the brutality of it? I wonder how brutal they would have been if there was NO audience. Can you even imagine? And in the last minute of the video, a police officer tells students to leave and then threatens "or we'll taser you too" after they ask for his badge number. Wait, i thought we at least ACTED like we live in a democracy... (and by the way, how brilliant that that was caught on video)

[3] It made my day to see, on the front page of the LA Times, impassioned students marching with signs taped to their chests saying "I'm Studying, Don't Taser Me". More often than not, the mainstream media picks up an outlier at a rally doing something really weird, to place as their photo representing an event. And if the event even gets a photo or article, it's usually nowhere near page 1. So thanks LA Times for placing the photo and article front and center. Did I just "thank" a newspaper for representing the peoples' voice?

[4] Back in 2004 (so long ago!) there was talk of tasers becoming available to the public for consumer purchase (yes, we're talking negotiations between taser manufacturers and the retail shop The Sharper Image. I wrote a post on this blog, and compared our society to that in Minority Report (Department of PreCrime).

[5] If it was a white boy who was asked to leave the library? He wouldn't be tasered, first of all. And second, if he was tasered, there would be no talk of well...maybe...why didn't he just leave...why cause trouble...maybe he deserved it...well not deserved it...but he was kinda asking for it... maybe he wanted publicity... and all the other twisted arguments I've heard.

[6] I love you cellphone videocameras. And I love you YouTube. There's nothing like you two. You've done so much for documenting and sharing in this world, and you are yet so very, very young.

(cross-posted at Los Anjalis)

Angels and Children

Hanging from the light in my exam room is a "flying angel" made of wood. Most people don't look up much, and if adults have noticed it, they haven't said anything. It's there as a message to spiritual and religious people to let them know they and their beliefs are welcome in the clinic, that we honor angels and mystery, of all kinds.

Twice now children have noticed the angel and have had really funny reactions.

One was a 2 year old who was playing with his mom's keys. He looked up, saw the angel, dropped the keys while his mouth opened wide in joy, and he just smiled the biggest smile i've ever seen on a two year old. He started jumping up and down pointing to the angel. The visit was about to end but he didn't want to leave so his mom picked him up and let him touch the angel, which seemed to calm him down.

Last week a four year old girl was hanging out during the visit with her mom. She was sitting on the floor and when she looked up she saw the angel and jumped to her feet and put her arms out like she was flying. She kept repeating, "un angel, un angel," while smiling and laughing.

:>

It's not a usual part of a clinic, most docs shy away from expressing spiritual beliefs. I've felt it to be an essential part of creating my practice. I don't claim any particular religion although I have a fancy for the Quakers approach to god and life. If only I could sit still for an hour i'd probably go to more of their circles. In the clinic, we all stay neutral, to be sure. There are alot of Mexican symbols, the Virgin Mary adorns the wall. With 80% Mexican patients, that seems relatively appropriate. But even so, we welcome Catholic, Evangelical, Traditional, Atheist, etc patients. I'm not sure what all the fuss is all about, I haven't had a conversation with other docs in quite a while about this but it seems that people are simply afraid to express their beliefs.

I'd love to hear other people's opinions on spirituality and religion in medicine.

andru

Family Practice Office UPDATE - Successes and Moving

Our little boutique medicine clinic for poor people has taken a few interesting and big growth steps over the past few months. I'm personally shocked and pleased that things are working out so well. I almost feel like we are defying gravity, breaking some physical laws of the universe but as I watch the patient volume grow by word of mouth, the complexity of medical disease increase, the flow of money continue to grow, and the interest in what we are doing in our community soar, it seems we aren't breaking any physical laws of the Universe, just alot of social and economic myths.

A look back at the last two years of patient volume shows the first six months with an average of 3-4 patients a day, the second six months with an average of 10 patients a day, the third six months with an average of 15 patients a day and the final 6 months up to now with an average of 20 patients a day. We had an all time high last week of 36 patients in a single day. don't ask me how we saw that many people in a tiny little house at the end of a dirt road with parking enough for about 5 cars, all in 6 hours. We are routinely now seeing 25 patients at least 1-2 days a week.

This has given us our first major problem - the wait time. Some patients are now waiting over 2-3 hours to be seen. So far everyone is very respectiful and thankful but you can feel the frustration mounting. The only solution is to bring on more practitioners or limit the number of patients we can see to 15 a day, which isn't going to happen. Out of everything that is going really well, the one thing that isn't is trying to find another practitioner to work with us.

On the financial level, the clinic is doing great. We have had an increase in expenses as our patient volume soared, paying for some office help, but we've been able to pay for it just from patient revenues to date. Both the nurse practitioner and I are making enough at the clinic, part-time, that we don't need other jobs anymore. I'm working my last two shifts at the Hospital this month and then I'm going to be able to focus all of my efforts on the clinic because the income is becoming more than I even wanted to earn in a year. I haven't done the full analysis yet but my hunch right now is that the money earned is roughly equal to what i'd make working for a big clinic system as a primary care doc.

With all this growth we have decided to move the clinic to a new location. We spent a year looking around for the perfect building and found a wonderful site just down the road. It's on a main intersection, a building that was initially built by a large hospital system in Albuquerque year ago. They outgrew it and moved down the street to a bigger buliding. So it used to be a clinic, it has a lead-lined room for an x-ray machine and is set up for most of our needs. Of course when they built it in the early 1980's they weren't thinking outside the box. They were so in the box that they built it with NO WINDOWS. Some notion of patient privacy, building security, something like that. We have some serious work to do to renovate/remodel the building but we are all really excited about the move. We will do all the work of renovation over the next two months and then open our doors at the new location in early January. The current owners of the building are a non-profit group called the Rio Grande Community Development Corporation (RGCDC). They are a great group of visionaries who have come together over the years to do economic develop projects but in their wisdom they recognize that without health, economic development doesn't go very far. And in our wisdom, we recognize that without economic development in this society, health doesn't go very far. It's a great beginning to a hopefully long partnership in bringing our efforts together for deep social transformation.

The really exciting part of the move is that the Kalpulli Izkalli traditional medicine practitioners are moving in with us and setting up an Altar. We are going to attempt to truly integrate the health services at our clinic by bringing togeher practitioners of very different kinds of medicines to see what we can do together for our patients. And on this note, we just found out that we were awarded a grant from a local foundation called "Con Alma" which means "with soul" in Spanish. The grant was written to help our groups come together over the next year, to provide some foundational support to the complex process we are engaging in.

So iive got lots more to say but i'll wait to post in another message. i'm trying to get back to sharing some of the good/bad/ugly of the clinic and the political work going on here.

andru

Geek and non-Geek activists throw down together!

I wish I had known about the Web of Change conference earlier — I’d be there in a second. I’m not a techy much myself (although in my circle of like-minded doctor folk, I come off as one, because I know what a “blog” is, but more so because I’m psychotically fascinated by how the internet and the "web 2.0" can help facilitate community building and power building. And I do enjoy discussing the similarities among peanut butter and jelly and the web 2.0 and health justice).

My friend Adrienne Marie Brown, an absolutely wonderful woman and the current Executive Director of the Ruckus Society, gave a session at this conference. I’m reposting Kate Milberry’s reportback from that session (and a link to it, on the web of change website is here). It’s beautiful (and where things are bolded, emphasis is mine):

Titilating Technology
Submitted by Kate Milberry on Thu, 2006-09-21 14:09.

Maybe you know Ruckus Society, maybe you don’t. But for those of us who didn’t know Adrienne Maree Brown before today’s session, we won’t be forgetting her any time soon. For starters, she made us sing. I was fine with that but, not being a singer (in fact, being almost tone deaf) I didn’t know this meant standing up. One gets lazy once one has parked one’s ass on the floor.

So, we all sang a note (which one, I couldn’t say) and it reminded me of church. I’ve not been in a long time, but still, the music (when not in Catholic mass - unless midnite mass on xmas eve) is typically uplifting. And in fact, it set the tone for Adrienne’s talk, which ended with her calling our geek work divne, and the geeks among us holy! Holy @%!*; that’s a nice compliment.

Adrienne started her talk as she ended it - on a tributory note. She said that geeks are key to the survival of folks like her - activists involved in the non-profit sector working for progressive social change. The work of geeks - their various tools, programs, apps, whatever - acts as a conduit for the things social justice activists are dreaming of, imagining and planning for.

One of her central points, and an underlying theme of her talk was this: technology only works if there’s a huge loving idea behind it. The problem, or sticking point, is that geeks don’t think of it this when actually developing the stuff. Adrienne’s message: don’t sell yourself short - you are the Justice League!

I thought it charming and refreshing that this self-described “wannabe geek” was throwing down w/some who are arguably hard core techs. Her presentation was lo-tech - no power point (or mac alt) but notes in a “cool” book that she referred to on occasion to ensure she wasn’t rambling. But even if (or when) she did ramble - it was highly entertaining. That girl is fun-ny! Even her invocation of Jesus was a yuk, surprisingly.

Another main idea of Adrienne’s talk was the need for integration (or interoperability?)- of social change software in the non-profit sector, in order for the sustainability of progressive organizing. So, techs, stop function in “silos” and start talking to each other.

One of the most resonant points of Adrienne’s talk, however, was the need for a theory of how change actually happens. We need to have one. And in thinking about this, organizers need to consider some crucial points:

1. Impacted communities are the ones who create change. Often social change activists are “do gooders” - we put ourselves in the position where we try to do good for impacted communities. BUT revolution is a personal thing that happens in your heart; people come together when something big happens, and people are deeply affected.

2. Invest in people not necessarily resources. It’s about moving people from a state of lack to a state of abundance, from needing to doing, from aloofness to leadership .

Despite the term “open source”, things aren’t always so open. Free software philosophy is not always practiced - we need to practice the change we want to see in the world. Share.

A closing point Adrienne made was this: We can’t expect to use the tools of the oppressor and expect a different outcome; that’s just dumb (her words)!! So what does this mean for techs? Build a new world through building a new technology. Developers are creating the systems by which we interact w/each other - this is powerful - let’s make something new! Not just a single killer app, but an integrated, holistic system that changes power dynamics, social relations - the whole thang.

Check out the rest of the posts on the Web of Change site — there are numerous interesting reportbacks on the site currently.

I’m excited about all this in so many ways, and this is personal, too, as I’m involved in two current projects (minus the pipe dreams in my head) related to health/medicine and health justice. I’m currently working with others on a subcommittee on web/technology for the wonderful National Physicians Alliance (I'll write more about this exciting organization in a future post on this space), and we’re trying to revamp the current site to become more interactive, more democratic/two-way, and more fun for those passionate about the issues that the NPA works on. That’s going to take up a bulk of my time in the coming months. The other project has moved officially from the “pipe dream” category to the “this is going to happen damnit, real soon, real soon…” category and involves a huge community of health justice folks. Both projects involve loving ideas and loving people behind them (see? project number two can’t still be a pipe dream if there are others working on it too!)

(this post cross-posted on Los Anjalis)

the "Green-House" of Healthcare:

For the past 7 years i've wanted to build a greenhouse on the south side of my house. it would reduce my $400-500 monthly winter heating bill, as well as add some beauty and capacity for winter veggies. three years ago i drew up some plans and got started and three years later i'm almost done with the foundation and frame... i call it turtle construction, slow and stead, making sure every nail, screw and piece of cement stands the test of time before another nail, screw or piece of cement is added. that's, of course, the bright side. From another perspective, i'm just a damn slow builder.

The greenhouse is being added on to a Victorian style house built in 1903 that was either constructed crooked or tilted over the years. there is not a single 90 degree angle in that house and the studs are never the same distance apart. as well, the wood used was truly 2 inch by 4 inch, not the smaller versions used today that are still called 2x4's but have shrunk HMO style to something that no longer has any fat or meat left over. pure bone, the new wood.

For the past 7 years i've been doing home construction to "relax" from doctor stuff, learning electrical, plumbing, demolition and framing skills on this tilted, awkward, frustrating, lovely old house. There was something simply elegant about putting in a new foundation, framing up a fresh new structure for the greenhouse, designing "from scratch." But when the greenhouse started butting up against the old house, all the old crooked demons of warped angles, erratic distances, different sized pieces of wood surfaced again and i realized something that felt quite profound.

The House of Medicine is like this 100 year old Victorian house. Crooked, intense, beautiful, frustrating, layers and layers and layers of things built on things built on ideas built on air. Like my house, it sometimes feels like the house of medicine was put right on the ground, with no foundation, no plumbing system, out of date wires. It works. For some people, in the master bedrooms, it works really well. But for many of us, practitioners and patients alike, it's a mess. Learning in it, working in it, receiving "Care" in it.

Out of this mess, I decided to build my own clinic, to start fresh, from "scratch," working with others who shared similar values. Set down the foundation, the frame, fill out the walls with beautiful windows, put on a solid roof and leave the door open for anyone to come in. But like my small greenhouse, it has to butt up against the house of medicine and therein lies all the intricate mess of history. Fortunately we built our "greenhouse of medicine" in such a way that the insurance system is out of range/sight/smell. They could be on another planet for all we care in our clinic. No CPT codes, no coding of visit lengths, no billing office, no checkboxes, no phone arguments over pre-existing conditions or prior authorizations. halleluyah. We only have to deal with labs, x-ray, MRI/CT and the occassional hospitalization. And with most of these external systems, we've had pretty good luck. Lab is fairly standard, x-rays are covered by an independent doc who charges $50-100 per shot, hospitalization has worked out amazingly well with a local non-profit hospital. MRI/CT is a mess, costs $500-3000, but we are working on it and have a potential solution coming down the road.

I know not everyone will agree with the grandiosity and negativity of this perspective of medicine. I don't mean to come off sounding black and white. the house of medicine does have some foundation somewhere. But please hear this criticism from a recent graduate of the system, from someone who has survived it's training programs and successfully built an alternative model that is working, that is making money charging 50-90% less than other operations. Whatever foundation we might have had in the past, similar to my victorian house (that was lifted from it's foundation on the other side of town and moved to it's present location over 50 years ago), large parts of our health system no longer seem to touch the ground.

The ground in medicine is science, research and common sense, connected to a trusting and powerful therapeutic relationship with our patients. Legal fears, Insurance relationships, personal/individual greed, and race/class factors all contribute to our instability as a coherent "house" of medicine.

andru

Move on out, sharks...

From "The High Cost of Being Poor" by Barbara Ehrenrich, author of the book Nickled and Dimed:

There are other tolls along the road well-traveled by the working poor. If your credit is lousy, which it is likely to be, you'll pay a higher deposit for a phone.If you don't have health insurance, you may end taking that feverish child to an emergency room, and please don't think of ER's as socialized medicine for the poor. The average cost of a visit is over $1,000, which is over ten times more than what a clinic pediatrician would charge. Or you neglect that hypertension, diabetes or mystery lump until you end up with a $100,000 problem on your hands.

So let's have a little less talk about how the poor should learn to manage their money, and a little more attention to all the ways that money is being systematically siphoned off. Yes, certain kinds of advice would be helpful: skip the pay-day loans and rent-to-pay furniture, for example. But we need laws in more states to stop predatory practices like $50 charges for check cashing. Also, think what some microcredit could do to move families from motels and shelters to apartments. And did I mention a living wage?

I love the idea of microcredit/microlending in the United States. LOVE it. For some reason i've been narrow minded in my understanding of the concept - I've always heard of microcredit working in other countries and hadn't thought of it as an option here, although i'm sure it's utilized in various ways in this country. (Microcredit is essentially lending to low-income unemployed folks or folks with no credit, with the idea that a bit of assistance for a small business or a family can allow the people involved to slowly generate income and not spiral further into poverty. Microcredit organizations around the world have been extremely successful, with most or all loans paid back in full, no sharks necessary).

So, anyone down with starting a sustainable microcredit lending organization with me? The gap between hard-working low-income families in Los Angeles and the wealthy folk is ever-widening (as is happening in many communities across the country). And the homeless population in the Skid Row area of Los Angeles increased almost 200 percent in the last year. Maybe this could be a move to turn the tide a bit (and kick out some sharks).

Reception Racism - Scandalous

over the past six months my clinic has tried to find an answering service to take calls for us when we are closed or super busy. it's a common service for doctor's offices and other businesses and i had the impression that it would be a simple thing to find a company to answer the phones. how hard can it be? for my clinic, we have simple needs on that level - tell people the hours, basic info about the clinic, and help them with directions. we don't even do appointments.

let me share with you my disappointment and insights.

my main criteria when finding a company was that i needed bilingual services and a fair price. 60% of my patients are monolingual Spanish speakers. another 20% are bilingual but most of them are more comfortable in Spanish.

the first company, the owner told me she spoke spanish but after a few weeks it was clear that her level of Spanish was barely adequate to get a name and a phone number. she had assured me that she spoke the language. when i called to cancel the service she tried to negotiate with me to stay and told me that her house cleaner spoke fluent Spanish and would be able to help out. no thanks.

the seoncd company was more professional. my English speakers loved it for the most part but i was getting reports that my Spanish speakers were getting hung up on and facing angry voices on the other side of the line. i had some bilingual friends call to test the system and they corroborated the stories.

i have called every answering service in New Mexico, from Albuquerque to Las Cruces, and not a single one is bilingual. This is in a state that has Spanish language written into the constitution, that has a heritage of Spanish colonialism and has a very proud Hispanic population...

so what is going on? i see two forces at play.

1. from the many Hispanic owners/receptionists that i talked with, trying to find a company, most of them expressed a certain pride in their Spanish and believed that because it is part of their ethnic heritage, they had a right to claim they were fluent when their abilities were truly inadequate. when i would press the point and ask if each of them were able to SPEAK SPANISH, they would reply, "I'm Hispanic." this confused the difference between Spanish language skills and ethnic background, two distinct things.

2. from a long conversation with the manager of the second company it became clear that there was an element of active hostility that was generated against my patients because of Racism. she was very honest with me about the internal process that was happening and told me that she had a parent from Mexico so she was sympathetic to my cause. here's what happened.

when i contracted with the second company, it was clear to them that they didn't have enough bilingual receptionists, so this manager promised to find and hire them. i did a major advertising campaign amongst friends and patients to get people jobs with the company and they did hire some. the company structured a small raise for bilingual receptionists, above what English-only receptionists would get. the focus on Spanish and the raise caused a ripple of resentment to flow thru the receptionists and they took it out on my patients because they couldn't say anything to their manager... underneathe it all was a sense that Spanish speakers don't belong here, a sort of nationalism/racism, bigotry and anger...

the really sad part of all this is the abuse of power displayed by these receptionists. they stand in a position of power, able to help or harm vulnerable people who are seeking medical care for illnesses. it's unethical and inhumane. i used to have more tolerance but i'm at the point now where if people want to act like little napoleans or bigoted jerks, they can do so without my monetary contribution to their salaries.

even if our electoral democracy is a sham, our economic democracy is still vibrant. money talks and mine is gonna keep walking until i find the company that cares about their work on a professional level from the owners to the managers to the receptionists.

my next step is to look in Southern California...

andru

Sustainable Economic Development

about a year ago we fundraised $35,000 from private donations and two small grants to purchase an ultrasound machine for the clinic. we bought a small, portable, sonosite Titan machine, brand new, and started using it during urgent care hours, mostly for early pregnancy dating and miscarriage.

we also started a new business, called Access Ultrasound, run by two wonderful women who coordinate with licensed ultrasound techs and a radiologist to offer high quality abdomenal and pelvic ultrasounds for an affordable price. they charge $100 per study, noone is turned away. the Radiologist is semi-retired and gave us a great deal, $25 per read. the techs earn about as much as they do elsewhere but their gift to the process is extreme flexibility in the face of a slow building process.

currently the ultrasound business takes referrals from about 4-5 clinic, a few midwives and some nurse practitioners, in albuquerque and some very distant towns. word is spreading.

and just this past week the ultrasound business gave out it's first dividend checks to my clinic and to the Kalpulli Izkalli, our partners who run the Traditional Medicine clinic. $350. it was a proud moment for all of us. A first visible step towards sustainable economic independence in a way that supports and promotes people's health instead of preying on their wallets at their moments of vulnerability.

with a health system so out of control, so profit driven, and with some really good, relatively affordable technology available, it's hard work but doable for small groups to set up competitive businesses and make human scale profits that price fairly for the average working-poor person.

andale pues.

andru

FIBROMYALGIA - what the heck is this thing?

last night i worked a shift in the hospital, admitting patients from the ER to the floor. a 55 yo woman came in with concerning symptoms of stroke. right sided facial, arm and leg numbness. her motor exam was normal and a CT of her head was normal, it didn't show any stroke, but CT's can be normal with a stroke so the standard of care is to admit these patients, watch them overnight, get an MRI, an ultrasound of the heart and an ultrasound of the legs to make sure everything is working okay. that's about a $10,000 work up.

i've dealt alot with chronic pain. upon taking a history of the patient, she revealed that she had fibromyaligia, chronic fatigue syndrome, anxiety/panic disorder, depression, hypothyroidism and had a hysterectomy for fibroids, and most recently, her gall bladder removed for gall stones and pancreatities. she had tried a vast number of alternative medicines including acupuncture, herbs and remarkably, was not yet on chronic pain medications. she felt hopeless.

she had had a panic attack, one of her worst, the night her symptoms started and got scared because the numbness on her right side didn't go away.

what the heck is going on? what kind of illness is this? i don't believe she had a stroke. it was more like a peripheral nerve palsy. we got to talking, spent a good hour together. she had great family support, with about five really caring people in the room during the whole time. no easily identifiable stressors but then we got to NUTRITION. BINGO!. the woman is a coke fiend, not cocaine, soda. she eats mostly fried foods, still cooks in lard (manteca) an eats tons of sweets.

you don't learn nutrition in medical school. we are basically taught that food is calories, fairly interchangeable (carbs, fats, protein) and vitamins. we learn that study after study shows minimal benefit or harm with all kinds of combinations and permutations of these different entities. it's a mess from a physicians perspective. hard to advise on anything. even with diabetes, once the person has it we can safely say to avoid carbs but noone really counsels their patients at high risk that sugar might CAUSE diabetes.

i take a stronger stance. from my experience and lots of reading, this woman's chronic pain and fatigue make sense. and the failure of alternative therapies makes sense as well. teh most basic element in life, to sustain it and to promote health, is FOOD and WATER, followed closely by exercise. if someone is malnourished, you can give them all the drugs you want, it won't make them healthy, even if it makes their numbers look better.

this woman is profoundly malnourished. she has fed her cells on a diet of sugar and heavy, saturated fats for 45 years. it's simply the wrong fuel. i owe my education on nutrition not to medical school or residency training but to the many naturopaths, midwives and acupuncturinsts who have taught me how to see past the puree of processed research that compared plastic oranges to vinyl apples and sees no difference in outcomes.

by the end of our time together this woman was prepared to try changing her diet with the energetic and sustained support of her family. break the sugar addiction, remove the heavy fats, add in fiber and vegetables, clean out the liver and intestines (detox) and slowly begin to heal. perhaps i'm wrong, but for sure, that woman had hope, she had a pathway that she could follow, and one that didn't prey on her wallet or force her into a dependency role taking medications for the rest of her painful life.

Fibromyaligia, to me, is a combination of dietary disaster, sedentary life and complex stressors (emotional, financial, familial, work) that are unique to the United States of America at this point in history with our wealth, processed, non-nutritive foods, and car/TV/computer culture. speaking of which, i'm outa here. i need to go stretch and walk. before my chronic back pain gets any worse.

andru

Clinic Vignettes July 2006

yesterday we saw 23 patients, today (saturday) 15... we are too busy. patients are now waiting up to 2 hours to be seen, some are leaving before being seen. part of me feels bad, i hate for someone to have to wait so long, but at least here the prices are fair and we stay as long as we need to in each visit, ensuring the person is heard and cared for as best we can, once they get to their visit. i would love to see five more clinics like this in Albuquerque, at least. we need a resurgence of independent, local, fair-trade, neighborhood health clinics.

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chronic pain - i have about 14 patients on chronic pain medications from narcotics to benzodiazepines for anxiety/panic. Many doctors won't do this because they feel like they are promoting addictive beavior. I have similar concerns and I pay attention to the issue but i'm finding that my patients on chronic meds, with loving encouragement and some alternative medicine tools, are finding their way off of the meds within 3-9 months. i have had to send away two patients over the last year who were manipulating to the point where it felt unhealthy to me to even try to help them, but otherwise, i am really comfortable with the progress my chronic pain patients are making. It is a process of empowerment, phsychology, learning self-care and new behaviors in an environment of non-judgement that seems to be stimulating these transformations. people seem genuinely happy to have someone take their pain seriously at first and then work to help them find simpler, natural ways of dealing with it.


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Obesity - overweight and obesity are some of the fasting growing problems in the U.S. population. Why are people overweight? why isn't there a simple cure? one case this week highlighted the reality for me quite clearly. a 35yo woman, obese, with multiple physical complaints. she has been fully studied and all results are normal yet she continues to feel like something is wrong. upon further exam and questioning we determine she has alot of anxiety about her physical health. she has fairly good information about foods. she works in a bakery and loves her job, but only has one day off every two weeks and two small kids at home. she states that when she tries to quit eating sugars and fats, two things happen. 1. she is okay for 1-2 weeks and then she hits a major craving and satisfies it by binging. she is definitely dependent/addicted to sugar. 2. she works in an environment where everyone drinks coffee and eats sweets for breakfast and when she changes her diet she is castigated and punished by her peers who pick on her because of their discomfort.

it's a mess. we did some education work around healthy foods, flax seeds and aloe to help with her constipation and a full exam of her diet to remove all of her milk products. she knows she gets bloating and constipation with milk but thinks that if she isn't "drinking" milk directly it doesn't count, like in ranch dressing, milk in cereal, chocolate milkd and oatmeal, etc...

what i think is really going to help her is addressing her sugar addiction and the peer pressure, along with gentle encouragement to "follow her gut" around dairy use. we spent alot of time together and helped her find some behavior tools and flower therapy to strengthen her resolve against these two forces. sometimes just being conscious of the forces working against you is enough to empower you to overcome them. we'll see. obesity is not a simple problem, there is no simple cure.

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had a patient come in towards the end of thursday night. she had continuous vaginal bleeding for 3 months. she did a good job at home waiting to see if the symptoms would resolve but the bleeding was actually getting worse. she is 45yo and of course concerned that it might mean she has cancer. we were able to do a uterine biopsy during the same visit and arrange for a pelvic ultrasound within 1 week to evaluation for fibroids or cancer. I am proud of that. no hassle, fast, affordable service even for fairly complex medical problems. It's happening. We don't need big systems, or misManaged Care to attain quality and efficiency in healthcare. We need networking, collaboration, fair distribution of resources, affordable tools and medications, accessible hours for patients, safe places for people to come with their worries and fears, a focus on reducing pain with medical procedures... patient-centered care. not system-centered care. not lawyer-centered care. not research-centered care.

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AMAZING CASE:
35 yo man came in six weeks ago and was diagnosed with diabetes. this was new information for him. at the time, he seemed interested, so we did a complete dietary counseling session, started him on one medicine (metformin), and got some labs to see how bad his diabetes was. his hemoglobin A1C came back at 18. for those who don't know, below 6 is normal. 18 is the highest i've ever seen in my life. the patient came back to the clinic two days ago. he had truly changed his diet, cut out all sodas, started on flax seeds, nopal (cactus) and regular oatmeal (without milk). he was doing a great job recording his sugars and his average was already down to 130 which is just about the most remarkable improvement i've ever seen in six weeks. we ordered another A1C test for a week and i'm very excited to see what it comes back as. this is as close to a cure of diabetes as i've ever seen so far. and you could feel the man's pride during the visit, he was so happy with his success. it certainly helped that i was seriously so floored that i kept saying "WOW." he's hispanic, very into futbol, so at one point i looked right at him and said, "GOOOOOOAAAAAAAL." he loved that. :>

andru
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Medication Prescribing Errors

Institute of Medicine Issues Report on Medication Errors

The other day in the clinic a patient came in and told me he was recently in the ER with severe hypotension. He had a rough time, they poked him relentlessly to try to find a vein, wound up putting in a central line first in the artery by accident and then finally in the vein and after all that they wound up not needing to use the venous access since his blood pressure was resolving nicely with IV fluids from the initial IV started by the ambulance crew.

He is a patient i was seeing for chronic pain and chronic high level opiate use (pills). I was trying to help him detox off the narcotic medications and I had used a routine medication, Clonidine, (a blood pressure medicine). It is usually started at a fairly high level for people detoxing off opiates and then weaned down as their symptoms of withdrawal ease. He had started it two days prior to his emergency.

Turns out that he had high blood pressure, was already on three blood pressure medications, but i didn't review his medications before starting the new drug. It was in the chart right in front of me. A dumb and potentially dangerous oversight on my part.

I recognized my mistake while he was telling me the story of his ER visit and started to apologize. It is part of my practice philosophy to own my mistakes and apologize, and even to refund money if the person feels harmed by an error. While i was attempting to apologize, he was very kind, and refused to accept my apology. He acknowledged that the error was mine but didn't feel angry. Somehow in the matrix of life, he actually felt even more strongly about getting off the narcotics and was prepared for another round (without the Clonidine) after resting for a month.

While he refused to accept my apology, out of kindness to me, I know he heard it, I could see him relaxing a bit as I acknowledge my error. he felt validated for his fairly rough experience in the ER and the bill he will now have to deal with. Contrary to the fear promoted by insurance companies and professional physician organizations, honest apology works as a powerful form of malpractice protection. most people are reasonable until they feel betrayed or abandoned by their physicians and then they get upset and use whatever tools are available to them to "get even."

This seemed a fairly timely incident to discuss given the most recent report by the Institute of Medicine citing medication errors as a huge cause of morbidity and mortality. You can bet that I read it carefully and will now be more vigilent with my prescriptions. I find their recommendations to be fair and accurate and even useful. see below.

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Institute of Medicine Issues Report on Medication Errors


More than 1.5 million patients are estimated to be injured each year
by medication errors, a committee of the Institute of Medicine
reported Thursday.

The committee's report, "Preventing Medication Errors," was written
at the behest of the Centers for Medicare and Medicaid Services,
which intended to estimate the incidence of drug errors and identify
the best preventive strategies against them.

Among the report's recommendations that directly affect physicians:

-- All prescriptions should be written electronically by 2010.

-- Providers should improve communication with patients about how to
take drugs safely and about potential risks.

-- All medication mistakes should be disclosed to patients.

-- Doctors should use electronic decision-support tools to write
prescriptions.

-- Physicians should regularly review all medications with patients
and other providers involved in a patient's care, particularly when a
handoff occurs.

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Yes, I'd like a 7-layer burrito, oh wait hold up lemme check my PDA


Yesterday evening i spent some time trying to update the programs on my Sony Clie NX80 PDA to better assist me in the hospital. I was checking out some freeware and came across the taco bell calorie counter!

Now I can switch up my order at the drive thru window after reflecting on how many calories my 7 layer burrito contains. Or, I can show a patient how his 2600 calorie taco bell diet is hindering him from losing weight. Oh, the uses of this application!

Delivering another message around OB...

We've been caring for pregnant women at the office who fall thru the chasms in the system and have no affordable place to go. Most recently I cared for a woman who got caught in a crossfire between Medicaid and the Public Hospital. She was uninsured, working, earning too much to qualify for Medicaid, too little to pay for private insurance. By the time she registered at the public hospital she was no longer working so they told her to apply for Medicaid again before they would put her on their payment plan. No resolution yet and she's already had her baby...

finances aside, i had the opportunity to follow this patients progress while in the hospital. I have a few thoughts to share. i had worked for 6 months helping this woman face her fears around pain, her underlying depression and fear around becoming a mom, the tensions of her relationship with her husband, her stress and anxiety around the hospital bills. Towards the end of the pregnancy she was particularly ancy about having the baby as soon as possible, ready to get the whole experience over with. we did some counseling and some therapies to help her relax, accept the pace her baby and her body were setting and find some joy and peace in her pregnant condition. and she was shifting, relaxing, enjoying.

when her contractions started, 5 minutes apart, she went in. she was 4cm so they admitted her. She entered the hospital with a smile, ready to birth as naturally as possible. her progress was slow so after a few hours they augmented her labor with pitocin which made it more painful for her. at 7cm they ruptured her membranes in an effort to speed things up. up till that point she was laboring without pain meds but once the membranes were ruptured her pain increased significantly (a well known reality is that the intact bag makes laboring more comfortable, a cusion effect for the mom). after an hour she needed an epidural for the pain, it slowed her progress down, she almost needed a c-section and in the end, the epidural wore off before the baby birthed so she wound up feeling most of the final labor.

her first words to me back in the clinic with a 3 day old baby were - "it was so painful." not, "it was so beautiful, look at my baby, what joy i'm feeling." this is a problem. more easily visible from outside the hospital than inside. the focus on rushing, on controlling every variable, and the ignorance of the subtle and deep personal issues of each case are a bad combination of factors that lead to excess intervention, dehumanized experiences, a focus on pain and suffering instead of enjoyment to achieve what we euphamistically call a "good outcome." the baby didn't die, the the mom had no physical complications, and she didn't sue.

there's no reason why a few different pathways couldn't have been activated successfully. she could have been sent home until her contractions were closer together but we use 4cm as the magic number for admission for everyone. there is no reason why she couldn't have walked and walked and walked inside the hospital until she was in true active labor. there is no reason why they had to rupture her membranes. babies can be born with the membranes intact and removed after birth. in some Native American cultures that is considered a very special, powerful omen for the person's life.

no doubt this patient was anxious, scared and eager to make the process happen faster. in a "karmic" sense, she got exactly what she wanted so this isn't so much a complaint against the system as an expression of frustration. the patient could have chosen to stay home longer, until her contractions were closer together. (i know many women who stay home until they can no longer tolerate it. they show up to deliver their babies fully dilated. it frustrates the heck out of nurses and doctors because they aren't then in control of every aspect of the labor but it means less interventions for the woman, which some prefer.) at the same time, docs and nurses in these big institutions could make sure that the patient is fully informed before each intervention. they never told her they were going to rupture her membranes. it was an ASSUMED decision by the doctor, not chosen by the patient. i remember when i was a resident that i would have been frustrated if someone told me that rupturing the membranes required informed consent, it seems like such a small detail in the BIGGER picture of hospital care, but when the bigger picture is patient comfort, patient-centered care, quality of care, it is front and center.

andru

In Labor

I'm finally a second year resident in family medicine (yikes!). 2nd year started off with a bang -- I'm on week two of working at a hospital in downtown Los Angeles, doing obstetrics/gynecology. That means I'm triaging women who are possibly in labor early or in labor on time, admitting women to the Labor & Delivery section of the hospital, delivering babies (YAY!), assisting in cesarean-sections, and caring for women for the 1-3 days they're in the hospital after deliveiring their babies. I'm working with both physicians and midwives, which is a great experience. I've got lots of stories from my past week, but yesterday I worked overnight, and my last patient in the early AM hours was a 17 year old girl who came into the hospital to be evaluated because she was having contractions regularly. She was 39 weeks pregnant, so contractions would make sense, she was in active labor and ready to deliver her baby. The only issue? Well, she hadn't told her parents until that morning that she was even pregnant. They were livid, but calmed down appropriately in time. But what? She lives with them, and they didn't notice that she had gained weight or looked different. And in the process of not telling anybody, she never got any prenatal care. A social work consult was in the works, and I hope everything ended up going well in her delivery, which happened after my 28 hour shift.

During this month, i'm improving my baby delivering skills but also observing how the senior residents and attending physicians and midwives "coach" laboring women and gain great rapport with them as they're going through some of the most intense pains any of us may ever feel. Humor during this process really helps, and as we're crouched in front of a woman's vagina, coaching her to push as if she's having a bowel movement (to push the baby out of the vagina), the first bit of the baby we obviously see is his/her hair. So some of the more recent hair comments by the physicians:

"Oh my goodness, your baby has hair! We're off to a good start"
"Hmm...mommy your baby has black hair, no highlights"
"No way, your baby has a mohawk!"
or "No way, your baby has dreds!"


Day Labor

So moving on from the hospital to the folks who make it run -- nurses. Right now a battle is being waged against them by Bush's National Labor Relations Board:

In a series of pending cases known as Kentucky River, the Bush board could strip what remains of federal labor law protections from hundreds of thousands-perhaps millions-of workers whose jobs include even minor, incidental or occasional supervisory duties. The pending cases involve charge nurses in a hospital and a nursing home and lead workers in a manufacturing plant, but these workers could be just the tip of the iceberg.

The Bush National Labor Relations Board is easily the most anti-worker labor board in history, but even against this sorry backdrop, the scope of what they now are contemplating is breathtaking....

The stakes are high for the public, too. In health care, for example, scholarly research has documented that heart attack survival rates are higher for patients in hospitals where nurses have a union than in hospitals where nurses do not.

Already in 2000, months before George W. Bush was declared president, Human Rights Watch issued a powerful report that found U.S. labor laws were grossly out of compliance with international human rights norms. That organization's bill of particulars was lengthy, but the first item on their list was the failure of U.S. labor law to cover millions of workers, including among others, managers and supervisors in the private sector...

It is therefore imperative to push back against the Bush board's assault on workers' rights. We must, moreover, go beyond good defense; we must win serious protections for workers' rights. The Employee Free Choice Act (EFCA) is the most significant federal legislative proposal in nearly 30 years to protect the freedom of America's workers to form unions and bargain collectively. Since its introduction in the 109th Congress by Ted Kennedy, D-Mass., and Arlen Specter, R-Pa., in the Senate (S. 842), and by George Miller, D-Calif., and Peter King, R- N.Y., in the House (H.R. 1696), EFCA has garnered 215 House cosponsors, just three shy of a majority, and 43 in the Senate...

(from Lawless Workplaces by Stewart Acuff and Sheldon Friedman of AFL-CIO

And more from AFL-CIO:

Have you ever shown a co-worker how to perform a task, or been asked to look over someone else's work? If so, your freedom to form a union and bargain collectively is in danger. The Bush-packed National Labor Relations Board (NLRB) is considering three cases that could alter the definition of supervisor—and that could mean hundreds of thousands of nurses, building trades workers, newspaper and television employees and others could be prohibited from forming unions...

During the week of July 10, hundreds of thousands of union members will take to the streets in a week of action to fight for their right to union membership. Already, some 7,000 nurses and other health care workers at eight New Jersey hospitals threatened to strike to protect nurses' right to speak out for their patients through their union.

You can send a quick letter to your congresspeople here.

And from the California Nurses Association:

The National Labor Relations Board will soon issue a major ruling that could jeopardize the ability of RNs to receive the protections afforded by CNA/NNOC representation. At the request of healthcare employers and anti-union consultants, the Board is expected to make the absurd ruling that many thousands of RNs are "supervisors" under the law because they make clinical patient care assignments to other staff. Under federal labor law, supervisors have no protection. THEY HAVE NO RIGHT TO UNION REPRESENTATION.

This coming Tuesday, CNA is organizing rallies in Los Angeles and Oakland. More info here.


Art and Labor

On a very related note, I'm hoping to check out the "At Work: the Art of California Labor" exhibit at Pico Gallery, Downtown Los Angeles, sometime in the coming month. Details below and more information here, comment below or email me if you're interested in joining me or if you've already checked it out! Looks good...

The story of labor - which comprises passionate struggles and triumphs as well as dehumanizing forces - has figured largely in the art of our time. At Work: The Art of California Labor exhibition opened at the Pico House Gallery at El Pueblo de Los Angeles Historical Monument on June 13, 2006. It is the first exhibition to explore this important topic through the eyes of artists who witnessed or were inspired by some of the most significant trends and events in the history of the 20th Century...

Many Californians are aware of San Francisco's 1934 General Strike, but probably few realize to what degree labor movements shaped the state's political and social climate. Even fewer know of the copious art which both inspired and reflected California's labor struggles throughout the 20th century. "At one time, the strongest and most important artists in California made art about labor," explains Mark D. Johnson, Professor of Art at San Francisco State University. A mid-century backlash, however, including the persecution of labor sympathizers in the McCarthy era, has all but erased from public memory the very "vast and compelling" art surrounding the labor movements, he says.

And lastly -- Manual Labor

Ending on an upbeat note (pun intended), join me for some manual labor, aka dancing, each of the next 3 thursdays, at the Root Down party at the Little Temple in the silverlake area of Los Angeles. I've got each of the next 3 fridays off and I'm working each of the next weekends, so it's party time each thursday night, and this party/movement is where it's at.

(cross-posted at Los Anjalis)

Gall Bladder Emergency;

about a month ago a woman entered the clinic jaundiced and feverish. no abdominal pain, no vomiting. her vital signs were normal so we felt safe to order some lab tests and figure out what was going on. we did the usual liver and hepatitis tests. the results were very concerning for gall bladder disease. the patient was still relatively asymptomatic so we continued with an outpatient workup, ordered an ultrasound and results showed a markedly diseased gall bladder with a dilated common bile duct (indicating a stone stuck in the duct system). Even though she was still relatively asymptomatic, the reality of her labs and ultrasound demanded an immediate surgical consult.

at this point my stomach always lurches a bit because the usual reality is anything but pretty for uninsured patients, especially undocumented immigrants.

i called the publid hospital, and for those who have read my posts before, guess what the response was.

WE'd LOVE TO HELP, SOUNDS LIKE SHE NEEDS SURGERY BUT WE HAVE NO BEDS.

Okay. Texas is a big rich state, perhaps i will start sending my patients there... Another idea that crossed my mind was to buy her a ticket to Canada. Years ago i had a roommate who was doing a musical tour in Canada. He was in a car wreck, not too bad, but was brought to an ER and evaluated with x-ray and CT scans. On the way out the door he tried to pay and the doctor said, "don't sweat it, we have national health insurance here, it's basically paid for, there is no bill for you."

check out this irony. another roommate at the time was Canadian. she was here in the USA as a student. she got sick, abdominal pain, and wound up in the ER at our local public hospital. everyone assured her there would be no cost to her, she was savvy enough to ask before being seen. after a few weeks the bills started arriving and she had to pay $800 for the visit. guess how mucha round trip ticket to Canada is. under $800. she could have flown home, gotten free healthcare in Canada and taken two weeks of vacation and come out about even.

okay, so it might be difficult to put a very sick undocumented immigrant on a plane to Canada. i assume it breaks alot of governmental laws, even though it honors human rights and the laws of ecnomics and free trade, but that's another story.

so lately i've been offering the option to my patients to go to other hospitals in albuquerque, names Presbyterian, which is the only other non-profit hospital in town. they have been known to disocunt bills significantly for working poor uninsured patients.

i called the surgeon at Pres and was treated a rare medical miracle. The surgeon was amazing on the phone. respectful, thoughtful, supportive and eager to see the patient. Most times docs ask the insurance status of the patient. She didn't. when i offered to her the social and financial issues, she shrugged her shoulders and said to send the patient right over.

the hospitalization turned out to be fairly complex with a 9 hour surgery. while the patient didn't look sick by her symptoms, she was actually on death's doorstep. this surgeon saved the patients life. i have already written a letter of gratitude to the surgeon because i was so touched by her compassion and perspective and desire to help someone who needed help.

while the patient is also super appreciative, and has already started to pay her bill, the total came to about $50,000. gulp. out of the frying pan, into debtors prison. perhaps Canada wouldn't be such a bad place after all for this patient and her entire family... Pres is a non profit and offers some discounts so my volunteers are helping her fill out the paper work. we'll keep you posted.

andru