It seems to me that recently there has been a move towards avoiding personal responsibility - after all, if something goes wrong, so much the better to blame someone else rather than yourself, right? I was just listening to NPR's "Talk of the Nation" asking the question, "Who's to Blame When You Get Drunk?" and I'm disgusted to hear talk of making the bartender responsible (legally and morally) in cases where the person is obviously intoxicated. Wait a minute - was the bartender force feeding the alcohol to the patron? Who qualifications does the bartender possess to be able to make this determination of obvious intoxication? Is the bartender liable to further civil suits, e.g. if he refuses to serve someone of another race and is then accused of racial discrimination?! Further, where do we draw the line? I see hardly any difference between the scenario of a person who's clearly intoxicated purchasing more alcohol and being served and an obviously, morbidly obese person purchasing high calorie meals at a fast food restaurant. In both cases there are "clear visible" indicators (although again, I ask, what qualifications do the servers possess that will enable them to make this determination in an equitable and objective manner?), clear negative potential consequences (drunk driving, health-related issues including diabetes, etc.), and occassionally false/seductive advertising (strong proof than advertised/perceived, greater calories than advertised/percevied).
Ironically, I feel this attitude pervades even into the medical establishment. When something goes wrong, it's rarely a single person's fault, e.g. the attending. No, it's the system's fault - the nurses, pharmacists, doctors, and the whole infrastructure. Hence the whole emphasis on systems analysis. Whatever happened to ideas like commander-in-chief, captain of the ship, pilot-in-command?
In the air, there is always one person designated as "Pilot-in-command" (PIC), and no matter what else happens - even if air traffic control dictates one thing or other, the PIC is the sole person responsible for the safety of the flight. It's a serious responsibility, and one not taken lightly. I would venture to guess that a similar idea exists in the captain of a ship, and there is still some vestiage of that notion in drivers of vehicles - you don't see people complaining about system errors when they are involved in accidents/incidents - they are held accountable. Period.
Similarly, I feel the attending doctors should step up to the plate and take responsibility for everything - even the actions of the medical student. Ultimately, it's under his authority that the student is acting/learning. There should be an equivalent "Doctor-In-Command" principle and dictates no matter who says what, what rules exist or are absent, that doctor is ultimately the sole person responsible for the health and safety of the patient. Period.
So who's to blame when you get drunk? I think the keyword here is "...when you get drunk" Who decided to drink? You. Who decided to drink more than you should? You. Who decided to drive after driving? You. As others have pointed out in the comments for that NPR article, who decided to drive to a bar, intending to drink, and then walk out intending to drive home? You! Gee - who should we blame, then?
How about that argument that once you become intoxicated, you lose your ability to think clearly and make proper decisions. Gee - if a person became that intoxicated, and the bartender cut him off, where do you think he's going to go next? That's right - back into his 20,000 pound SUV and drive to another bar or go home. Do you think that a person who can no longer be trusted to make a judgement call as to whether or not he's had "too much" is perfectly fine to drive a vehicle? How does cutting him off from further drinks help this situation? Are you then going to have the bartender make sure that he's not driving? What if he walks back to his job (a surgeon, let's say) and kills someone? Who's responsible then?
Monday, December 29, 2008
Tuesday, December 23, 2008
Keys
When I was a kid, I used to love keys - they represented to me power and responsibility, I guess - a symbol of adulthood. I still recall being especially proud of having a nice large key ring with many keys - bicycle locks, house keys, and even keys for such small things as diskette storage bins, etc. Now that I'm older than 30, I find myself appreciating smaller key rings. I've since shed most of the ancillary keys, keeping just the bicycle lock, house, and car key. I hope it's sign that I'm maturing...
Sunday, November 9, 2008
Comment on 2008 presidential election result
The elephant is in the room, and nobody is talking about it. Why is it that race is such a charged matter? For me, that defines "racism" - not the typical negative comments/feelings towards another race, but rather that any distinction is paid to race at all (other than for scientific purposes, e.g. determining phenotype/genotype frequencies and healthcare outcomes). The focus on race itself is racism, and not all racism is necessarily "bad". I'm just calling a rose a rose.
This whole thought started when I kept hearing, repeatedly on NPR, reports of how "little race" mattered in the Presidential election, how they were so proud that exit polls showed race only placed a part in the decision-making process of who the next president will be in 8% of all voters.
Well, I have a different take. Look closely at the exit poll results, and as many of the pundits are pointing out, the blacks overwhelmingly chose Obama over McCain. Nearly 100% of blacks in New York state voted for Obama according to their exit polls - how can this not be a reflection of race?
One might argue that perhaps the blacks simply liked Obama's platform better, agreed more with his views and political position. While this might be true, I find it incredibly hard to believe that he won over nearly the entire black population by his politics. Obama only gathered around half of the white population (and whatever happened to non-whites, non-blacks: Asians, Latinos, etc?) I find it very hard to believe that the decision to vote for Obama was not motivated by race.
I'll admit - even I (had I voted) would've been tempted to vote for Obama simply because it would be a historic event, just as if Hilary had been a candidate I'm sure she would've gotten a strong boost from women voters just do demonstrate that it's possible (and for this reason I worry about 2012 election if Palin decides to jump in).
Anyway, this is fertile ground for arguments and disagreements, so I'll leave it here at that. I just feel people should acknowledge the poor elephant sitting in the room to whom nobody is paying any attention. This presidential election was strongly influenced by race, and for that reason I, too, worry about what the future may bring. If Obama manages to miraculously recover this country's economy in one term (I feel the American public will be impatient and give him only one term), then all is well. On the other hand, if he fails or if the economy gets worse (very likely given the current financial situation coupled with the continued drain on resources due to the war in Iraq and Afghanistan), he not only will be be blamed for the outcome (wrongly, I feel), but it would cast a dark shadow for any future black presidential candidate.
This whole thought started when I kept hearing, repeatedly on NPR, reports of how "little race" mattered in the Presidential election, how they were so proud that exit polls showed race only placed a part in the decision-making process of who the next president will be in 8% of all voters.
Well, I have a different take. Look closely at the exit poll results, and as many of the pundits are pointing out, the blacks overwhelmingly chose Obama over McCain. Nearly 100% of blacks in New York state voted for Obama according to their exit polls - how can this not be a reflection of race?
One might argue that perhaps the blacks simply liked Obama's platform better, agreed more with his views and political position. While this might be true, I find it incredibly hard to believe that he won over nearly the entire black population by his politics. Obama only gathered around half of the white population (and whatever happened to non-whites, non-blacks: Asians, Latinos, etc?) I find it very hard to believe that the decision to vote for Obama was not motivated by race.
I'll admit - even I (had I voted) would've been tempted to vote for Obama simply because it would be a historic event, just as if Hilary had been a candidate I'm sure she would've gotten a strong boost from women voters just do demonstrate that it's possible (and for this reason I worry about 2012 election if Palin decides to jump in).
Anyway, this is fertile ground for arguments and disagreements, so I'll leave it here at that. I just feel people should acknowledge the poor elephant sitting in the room to whom nobody is paying any attention. This presidential election was strongly influenced by race, and for that reason I, too, worry about what the future may bring. If Obama manages to miraculously recover this country's economy in one term (I feel the American public will be impatient and give him only one term), then all is well. On the other hand, if he fails or if the economy gets worse (very likely given the current financial situation coupled with the continued drain on resources due to the war in Iraq and Afghanistan), he not only will be be blamed for the outcome (wrongly, I feel), but it would cast a dark shadow for any future black presidential candidate.
Saturday, November 8, 2008
In the pursuit of happiness
Just reading an old blog entry from a friend who pondered, "Is the pursuit of happiness all about selfishness? Can we achieve happiness without causing pain to others?"
I believe that the answer is "yes" to both questions. Happiness, by definition, is completely subjective and self-centered. True happiness comes only from being honest to one self, and therefore is "all about selfishness". One must disregard all other factors in the pursuit of happiness.
However, at the same time, there is no reason why happiness for one must cause pain for another. While one must entertain the possibility that happiness for two people can be mutually exclusive, a clear example where happiness is synergistic can be found in the traditional notion of a "romantic couple". It remains to be seen (at least for me) whether or not such a notion is entirely accurate or portrays a realistic scenario. More concrete examples can easily be found in the accomplishments of any group of people. Take, for instance, the profound joy and happiness the entire group of scientists and controllers at NASA must have felt on their Mars Rovers' success.
On the other hand, in any type of competition where there are clear winners and losers, happiness to the winner comes at the cost of pain to the losers. Life, I believe, is an eternal struggle - order against chaos at its most fundamental level. So while it might be said that happiness for one must come at a cost to others, considering that life is a constant competition (against death?) - that's a very narrow view precluding the possibility of cooperation, group formation, and team work.
I believe that the answer is "yes" to both questions. Happiness, by definition, is completely subjective and self-centered. True happiness comes only from being honest to one self, and therefore is "all about selfishness". One must disregard all other factors in the pursuit of happiness.
However, at the same time, there is no reason why happiness for one must cause pain for another. While one must entertain the possibility that happiness for two people can be mutually exclusive, a clear example where happiness is synergistic can be found in the traditional notion of a "romantic couple". It remains to be seen (at least for me) whether or not such a notion is entirely accurate or portrays a realistic scenario. More concrete examples can easily be found in the accomplishments of any group of people. Take, for instance, the profound joy and happiness the entire group of scientists and controllers at NASA must have felt on their Mars Rovers' success.
On the other hand, in any type of competition where there are clear winners and losers, happiness to the winner comes at the cost of pain to the losers. Life, I believe, is an eternal struggle - order against chaos at its most fundamental level. So while it might be said that happiness for one must come at a cost to others, considering that life is a constant competition (against death?) - that's a very narrow view precluding the possibility of cooperation, group formation, and team work.
Tuesday, July 22, 2008
Mistakes
There have been many times I've made a mistake and caught myself - making me wonder how many OTHER times did it just slip through? For instance, today I was assigned a patient transferred from the medicine floor and I carefully read over the progress notes as is my habit. I noticed that the patient had originally requested do not resuscitate (DNR) which was rescinded for a procedure. I felt so proud of myself in getting the DNR back on board to ensure that things happened to the patient's wishes. The nurse in charge of the patient was aware of the DNR status. However, I then notified the nurse monitoring all the EKGs on the floor about the DNR order. She got a bright orange sticker and proceeded to identify the patient as DNR. Luckily, in that moment, a nurse came over and asked me a question about another patient. That's when I realized...I had told the monitoring nurse the wrong patient!
It would've been a potential nightmare had that patient coded and we mistakenly withheld life-saving measures thinking he desired not to be resuscitated (and clearly by then the patient would not be able to object to our inaction). The nurse probably would have picked up this error and nothing would have happened, but seeing as this was a night team signing on, unfamiliar with the patients, there was a potential for serious harm if not at the minimum serious confusion.
My lesson? Never trust my brain. Always look at the piece of paper in my hand, and do not rush important things like DNR orders.
It would've been a potential nightmare had that patient coded and we mistakenly withheld life-saving measures thinking he desired not to be resuscitated (and clearly by then the patient would not be able to object to our inaction). The nurse probably would have picked up this error and nothing would have happened, but seeing as this was a night team signing on, unfamiliar with the patients, there was a potential for serious harm if not at the minimum serious confusion.
My lesson? Never trust my brain. Always look at the piece of paper in my hand, and do not rush important things like DNR orders.
Sunday, June 1, 2008
On healthcare costs
Just listened recently to yet another news story about soaring health care costs and the sub-optimal care Americans get despite the cost. I still fail to see why fee-for-service is such a bad idea. Back before the days of HMOs and health insurance, people would pay the doctor for a visit - simple as that. But what about hospital stays? Who paid then? The individuals? Hospitals, probably even back then, were probably very expensive. Never mind all the new technologies and tests we have now that make health care so much more expensive - how did people pay for the basic nursing services of a hospital admission? Now I'm curious to find out...
Ok, just finished reading a long and interesting article on health care costs and insurance. The issue is really much more complex than I had originally thought, but my basic premise I believe remains the same. You cannot simply give people a product or service and request that they pay for it later (a la model of NPR). Most people are, by human nature, opportunistic. If you give them something and then request a "donation" later (similar to shareware model, etc.), few if any people would ever pay back no matter how wonderful a product/service you may have provided. You can extend this idea to health care as well but in reverse (this is true for most insurance models). We all pay a premium to the insurance company for a promise of future services. It's clear, however, that their goal is to retain as much of that money as possible and provide as few services as possible. Human nature. I believe the only way that insurance schemes can work is in a non-profit setting where you reduce as much as possible the motivation to hoard.
Arrgh - too complicated for my tiny brain. Let's all just hope we won't be needing those insurance services in the near future.
Ok, just finished reading a long and interesting article on health care costs and insurance. The issue is really much more complex than I had originally thought, but my basic premise I believe remains the same. You cannot simply give people a product or service and request that they pay for it later (a la model of NPR). Most people are, by human nature, opportunistic. If you give them something and then request a "donation" later (similar to shareware model, etc.), few if any people would ever pay back no matter how wonderful a product/service you may have provided. You can extend this idea to health care as well but in reverse (this is true for most insurance models). We all pay a premium to the insurance company for a promise of future services. It's clear, however, that their goal is to retain as much of that money as possible and provide as few services as possible. Human nature. I believe the only way that insurance schemes can work is in a non-profit setting where you reduce as much as possible the motivation to hoard.
Arrgh - too complicated for my tiny brain. Let's all just hope we won't be needing those insurance services in the near future.
Need to think before I open my mouth
We had just finished transporting an elderly couple to the hospital after his wife took a small spill (apparently, a common occurrence). The husband was very nice and grateful, and I started feeling a bit uncomfortable with all his thanks. So, I stupidly replied, "It's all fun and games to us!". He took it well, saying he knew that, but wanted us to know how much he appreciated our service.
In thinking back, thank god that was not a more critical situation. I didn't realize that I just made light of a potentially serious situation. Next time, I'll just say we enjoy doing this...
In thinking back, thank god that was not a more critical situation. I didn't realize that I just made light of a potentially serious situation. Next time, I'll just say we enjoy doing this...
Saturday, May 17, 2008
Funny moments in clinical clerkships
Since I posted the falling asleep at surgery, I figured I should follow-up with some of my other less exciting but just as hilarious faux-pas'. Where to start? How about insertion of foley catheters? A simple technique to be sure (especially in a male, but a bit more challenging in a female). I had watched at least 3 foley insertions into females when my opportunity arose. I grabbed the foley kit, placed it on the bed of the patient confidently, and then noticed that there were some instructions printed on the kit itself. Pausing for a bit, I started reading the instructions and that's when the patient asked, "Have you done this before?" in a worried tone. I answered truthfully, "Well, I've seen many done." "Oh - I'd prefer someone who's done this before, if you don't mind." The next time, I simply grabbed that kit, plopped it down, and ripped it open like it was my umpteenth time doing foley insertions. Alas, I failed to place it into the urethra correctly the first....second...and third time. However, I felt much better when the nurse failed, then the intern failed, then the floor "Foley specialist nurse" failed and we were on the brink of calling urology when finally the proclaimed Foley specialist was able to get urine out.
Lesson learned: Do not read the instructions on packaging in front of patients.
Another time, I was accompanying an elderly lady who had just "bounced back" into the hospital for possible small bowel obstruction due to her advanced ovarian cancer. The attending had just previously finished speaking with her daughters that the condition was such that surgical intervention was probably more harm than benefit so it was essentially palliative care only at this point. I was to escort the lady to get a CT scan to confirm the diagnosis and evaluate for other possible metastases. There were several other CT cases ahead of us so we have to wait in the holding area. Trying to pass the time, I attempted some light hearted conversation. I noticed they had placed some magazines in the waiting room, and I thought it was incredibly silly. Almost all the patients here in the holding area are lying in bed. So I mentioned this as a point of humor: "Look, they even tried to decorate this room like a regular waiting room. Are you interested in 'Country Cooking'?" Right after I asked, I realized how callous a question it was. The lady had been vomiting for the past few days and couldn't keep anything down due to the presumed obstruction and was probably still starving/feeling hungry. The woman smiled softly,however, and said, "No, thanks." Trying to salvage myself a bit, I eyed the magazine and asked, "How about 'Living'?" to which at first the lady said, "N-..well, yes, I am interested in that." I was horrified at what I had just asked. The magazine was "Living with Martha Stewart" but the "Living" part was the largest part of the title - the only part that I was able to read clearly from across the room. Not knowing what else to say, and fearful my mouth would only sink me into deeper depths of embarrassment, I shut up.
Those were the funny moments. How about the more recent humiliating moments? Like the time my attending asked me about Ranson's criteria. I had no idea, and was told to read up on it. That night (it my was 3rd day in surgery rotation), I visited my lab first where I fixed a few things before returning home. I then started reading the textbook and that promptly put me asleep. So, in the morning I had not yet read about Ranson's criteria for acute pancreatitis. I found out, however, that my scheduled surgery with the attending won't happen until 1:00pm meaning I should be able to find 5 minutes in lunch to quickly commit to memory Ranson's criteria. Saved - or so I thought, until the attending strode in at 7:00am. Opps - I forgot he was going to do morning rounds with us. The moment I saw him, I knew I was doomed. "Dr. Bien - what are Ranson's criteria?"
"Umm, uh uh...I don't know."
"You don't know?", incredulously, the attending asked.
"I didn't get a chance to go over that, yet"
"Let's see what your schedule last night was. You were finished around 7:00pm, and then you went home-"
"Actually, I went to lab and didn't leave until 10pm"
"Ok, then you ate for one hour until 11-"
"Well, I finished eating at 10:30 and then cracked open a textbook, then fell asleep," I said in a vain effort to save myself.
The attending didn't buy it for one moment. They had just paged someone, so he then said - "Let's round. Harold - since you didn't learn Ranson's criteria, stay by the phone and answer it when the doctor calls back and read about Ranson's criteria"
There I was, shamefully sitting in what in essence was the corner of a classroom wearing what might as well would've been a dunce cap, trying to read up on Ranson's criteria. Not the best way to impress the attending (who was also my preceptor, and thus who would have a profound influence on my grade). But on the upside - I finally did learn about Ranson's criteria!
Lesson learned: Do not read the instructions on packaging in front of patients.
Another time, I was accompanying an elderly lady who had just "bounced back" into the hospital for possible small bowel obstruction due to her advanced ovarian cancer. The attending had just previously finished speaking with her daughters that the condition was such that surgical intervention was probably more harm than benefit so it was essentially palliative care only at this point. I was to escort the lady to get a CT scan to confirm the diagnosis and evaluate for other possible metastases. There were several other CT cases ahead of us so we have to wait in the holding area. Trying to pass the time, I attempted some light hearted conversation. I noticed they had placed some magazines in the waiting room, and I thought it was incredibly silly. Almost all the patients here in the holding area are lying in bed. So I mentioned this as a point of humor: "Look, they even tried to decorate this room like a regular waiting room. Are you interested in 'Country Cooking'?" Right after I asked, I realized how callous a question it was. The lady had been vomiting for the past few days and couldn't keep anything down due to the presumed obstruction and was probably still starving/feeling hungry. The woman smiled softly,however, and said, "No, thanks." Trying to salvage myself a bit, I eyed the magazine and asked, "How about 'Living'?" to which at first the lady said, "N-..well, yes, I am interested in that." I was horrified at what I had just asked. The magazine was "Living with Martha Stewart" but the "Living" part was the largest part of the title - the only part that I was able to read clearly from across the room. Not knowing what else to say, and fearful my mouth would only sink me into deeper depths of embarrassment, I shut up.
Those were the funny moments. How about the more recent humiliating moments? Like the time my attending asked me about Ranson's criteria. I had no idea, and was told to read up on it. That night (it my was 3rd day in surgery rotation), I visited my lab first where I fixed a few things before returning home. I then started reading the textbook and that promptly put me asleep. So, in the morning I had not yet read about Ranson's criteria for acute pancreatitis. I found out, however, that my scheduled surgery with the attending won't happen until 1:00pm meaning I should be able to find 5 minutes in lunch to quickly commit to memory Ranson's criteria. Saved - or so I thought, until the attending strode in at 7:00am. Opps - I forgot he was going to do morning rounds with us. The moment I saw him, I knew I was doomed. "Dr. Bien - what are Ranson's criteria?"
"Umm, uh uh...I don't know."
"You don't know?", incredulously, the attending asked.
"I didn't get a chance to go over that, yet"
"Let's see what your schedule last night was. You were finished around 7:00pm, and then you went home-"
"Actually, I went to lab and didn't leave until 10pm"
"Ok, then you ate for one hour until 11-"
"Well, I finished eating at 10:30 and then cracked open a textbook, then fell asleep," I said in a vain effort to save myself.
The attending didn't buy it for one moment. They had just paged someone, so he then said - "Let's round. Harold - since you didn't learn Ranson's criteria, stay by the phone and answer it when the doctor calls back and read about Ranson's criteria"
There I was, shamefully sitting in what in essence was the corner of a classroom wearing what might as well would've been a dunce cap, trying to read up on Ranson's criteria. Not the best way to impress the attending (who was also my preceptor, and thus who would have a profound influence on my grade). But on the upside - I finally did learn about Ranson's criteria!
Tuesday, May 13, 2008
I fell asleep during surgery..and survived!
I knew it was bound to happen sooner or later. I often find myself dozing off at inappropriate times without much control on my part. For example, during lecture with our chair of surgery while I'm on the surgery rotation - I fell asleep right in front of him. With an attendance of just 4 students, it's probably impossible to miss noticing the one student who's head keeps jerking forward and backward. But I digress - I had feared, prior to entering 3rd year clinical clerkships, that I would fall asleep especially during surgery with the long hours and early mornings.
Well, it finally happened today. I was at a simple partial mastectomy (aka lumpectomy) with sentinel node biopsy. For some unknown reason, I got incredibly sleepy halfway into the procedure. Trying to keep awake, I grabbed the vacuum and attempted to "suction the smoke" from the electrocautery. Instead, I started to drift off. I usually caught myself drifting off in time to wake back up and prevent anything bad from happening, but this time - I fell completely asleep at least once where my eyes closed and I actually started to fall in towards the patient. Luckily, I woke up and arrested my descent and the attending did not notice (or at least didn't say anything). So, I calmly placed the vacuum aspirator back onto the operating table and then tried valiantly to stay awake. I fell asleep once more, nearly completely, and thank god the surgery was over. Lessons learned:
1) Falling alseep in surgery is not the end of the world
2) Make sure you eat something before embarking on a long day of surgeries
Well, it finally happened today. I was at a simple partial mastectomy (aka lumpectomy) with sentinel node biopsy. For some unknown reason, I got incredibly sleepy halfway into the procedure. Trying to keep awake, I grabbed the vacuum and attempted to "suction the smoke" from the electrocautery. Instead, I started to drift off. I usually caught myself drifting off in time to wake back up and prevent anything bad from happening, but this time - I fell completely asleep at least once where my eyes closed and I actually started to fall in towards the patient. Luckily, I woke up and arrested my descent and the attending did not notice (or at least didn't say anything). So, I calmly placed the vacuum aspirator back onto the operating table and then tried valiantly to stay awake. I fell asleep once more, nearly completely, and thank god the surgery was over. Lessons learned:
1) Falling alseep in surgery is not the end of the world
2) Make sure you eat something before embarking on a long day of surgeries
Subscribe to:
Posts (Atom)