Walking Pool of Incontinence

Darron is having his annual fundraising basketball tournament on 12/19 for the Sarcoma Foundation for his late friend. You can find out more about it by visiting his blog, I'm sure.

Ever heard of a fistula? Probably not, because it's a gross topic. This article gives you an idea about the problem. Essentially, when tissue heals, sometimes it heals all wrong. A fistula happens when tissues heals incorrectly between two pipes - like the trachea and the esophagus (the windpipe and foodpipe), or the vagina and the anus - and leaves a permanent hole connecting them. In babies with tracheoesophageal fistula from an error in development, they gag and turn blue when they try to eat, because food enters their lungs through that hole that isn't supposed to be there. In vaginovesicular (vagina/urethra) or vaginoanal fistula after a difficult childbirth, a permanent hole allows urine or feces to dribble continuously into the vaginal canal. If any of you has ever dreaded the thought of getting old and incontinent, this is your nightmare: being a young adolescent or teenage mother - likely by crime or at least social/cultural choice, not your own - having a difficult labor, then shunned from society for being disgusting.

When my life seems so hard, sometimes my breath is taken away by how awful my patients' and other unfortunate people's lives are. There are so many worthy causes out there, but with the holidays approaching, please consider adding this one to your list.

I better be careful with this blog, lest it become too much of a party pooper (haha, no pun intended) and my vast readership takes a dive.

My Heart Bleeds

The article.

International Medicine

Not that it was drastically different from the norm, but it was a little more concentrated than usual: the international flavor of my daily routine, beyond the normal Spanish and Vietnamese.

I finished my emergency medicine rotation and am now readjusting to being back in the inpatient medicine setting. Of our patients, we currently have a Korean man and his wife who speak very limited English, a Spanish-only spouse of a man rendered stuporous, a Romanian-only, and an Arabic-only speaking patient.

I am constantly surprised by otherwise very intelligent and caring medical professionals, who don't seem to be able to relate to English learners. Even if they are nice people who aren't purposely being mean toward a patient for not speaking English well, they don't seem to be able to modify their rate of speech or vocabulary. The same happens even with native English speakers that just have less education. The doctors continue to use idioms or phrases and words that are more advanced, like saying, "we anticipate he will leave soon" instead of just saying, "we think he will leave soon." Sometimes the low-level English speaker glazes over when they are faced with a few difficult words like this in a row, and I can tell they have lost the thread of the conversation. But the doctor will continue on, oblivious that the person isn't making obvious his or her confusion, perhaps due to embarrassment over suboptimal English skills.

This happens to me all the time in Spanish. I appreciate Spanish speakers who have lived in the U.S. for a while compared to Mexicans at the clinic I used to go to in Mexico through the Flying Samaritans. Even though both groups spoke only Spanish, the ones who had come to the U.S. generally knew to use simpler Spanish words and slow down so I could follow along. The ones without experience with non-native Spanish speakers would just chatter along at the speed of light, or use colloquialisms I had never heard.

I think I'm a pretty good contextual comprehender; it's how I blended into American life as a teenager without knowing teenage lingo or many swear words when I came here. It helped when I was in the fire department, whether it was banter in the firehouse or with the public out in the non-standard English-speaking neighborhoods. It's proven helpful when I traveled in Europe and South America where I often understood the gist of what was being said even if I didn't catch all the words perfectly. But tourist conversations hardly compare to the gravity of medical explanations and decision-making. It's hard enough for the lay person to understand medicine as it is, without a language barrier to compound problems.

In any case, all my non-English speaking patients and their families seemed happy at the end of the day. In particular, the Spanish-speaking spouse was adamant yesterday that we call an interpreter when they transferred him to our service. My Spanish isn't great, but the translator was going to take a while to arrive, so we tried her out anyway in the interim. At first she was dubious, but by today, she was appreciative, smiling and waving at me as I walked by the room. Her otherwise healthy husband has been gorked out for a month, the doctors at the prior hospital hadn't been able to fix him or even tell her what the problem was, and she was freaked out. The Koreans too, they were sad that they were stuck out here in California when all they wanted was to get back home to the Midwest, but they were a little happier when they had a better grasp of their care.

In a place like California, no one is going to learn every language spoken and there just aren't enough translators. But I think simply slowing down and using simpler words so people can understand really helps them cope with their medical issues.

Veggies

About a month ago a classmate on his family medicine rotation told us about the hypertension (high blood pressure) clinic he was at that week. He remarked that he was going to try the DASH diet that we tell patients to follow, which stands for Dietary Approaches to Stop Hypertension. Essentially, it is all about eating 10 servings of fruits and vegetables per day, especially at the beginning of a meal before getting to the other stuff like meat, bread, potatoes, etc. So I decided to give it a try too, not even paying attention to reducing salt, but just concentrating on the 10 servings.

It's hard! I'm so full after eating fruit and vegetables that I don't have room for much else. Of course, I also try to keep it reasonably low-fat, without actually going on an "official" diet. I don't pile on the butter, although I do use some to keep it interesting. And since I started this because I wanted to see if I could do what we tell patients to do, I also began to ponder how I could convince someone used to eating pretty unhealthily to start eating well. And I think the answer is in 1) changing expectations and 2) educating taste buds.

I was raised on plenty of veggies daily, and our minimum level was salad with dinner every single night. It was a very simple salad, but its mere existence got us accustomed to eating fresh vegetables, I think. Even for "movie night" where we had popcorn and chicken nuggets and potato chips, we also had carrot and cucumber sticks without fail. So even now I have a fundamental expectation that there will be some sort of vegetable to eat every day. In fact, if I don't have fresh veggies for a while, say I'm on a trip, I start really noticing their absence and missing them, just as I would unhappily notice if I hadn't eaten any meat or starch in several days.

A while back, my uncle Tom gave me bunch of veggies from his garden. They were delicious! And that is my second point. The typical Western diet is really just a super-saturated behemoth of taste. Like McMansions and SUVs, Americans tend to want bigger and more, like taking something sweet and adding something else sweet to it to make it even sweeter, instead of just enjoying the one sweet thing on its own. Like cake and ice cream with chocolate sauce. Deep-fried Twinkies, anyone? You get my point. It's just more! more! more!

In grade school I remember we did an experiment in science class when we were learning about the digestive tract and the enzyme amylase. The teacher told us that amylase starts breaking down starches into glucose in the mouth, even before the food gets to the stomach. And to illustrate this, we all took a bite of plain white rice. After several chews, the rice indeed started to taste sweet, and we were amazed! So really, veggies and grains have their own sweetness that we have trained ourselves out of being able to appreciate with our 30-teaspoons-of-sugar-per-can sodas. Of course steamed broccoli will taste bad when your taste buds are hungering for tons of cheese, salt, or ranch dressing; they're underwhelmed because they've been oversaturated for so long. But if you slow down a minute (take time to chew a little more and let that amylase start to do its thing) and actually learn to appreciate the subtlety of a vegetable, I think it starts to become a more enjoyable, and thus, sustainable operation. Growing your own is a great start, because you're already primed to have pride in and appreciate your creation.

This all is exactly the same as music or art or finances or NASCAR. To those unversed in it, classical music sounds all the same; so does rap or country music. Art can be pretty boring, especially modern art, which just looks like paint splotches to me, as can finance for those of us who just want to stick money somewhere and have it grow a bit. To the casual observer, NASCAR is just driving in circles. So appreciating fresh veggies is really the same as with anything; the more you take interest, the more you know, then the more enjoyment you get out of it, and eventually you will be able to discriminate higher quality from the crap.

I wonder if any of my patients will be convinced... what do you think? All right, back to the grind. I can't believe I wasted my study break thinking and writing about patients!!!

Attention Span

I find myself comforted by the fact that I get bored during long surgeries.  When they're interesting, surgeries definitely are fun to watch or to help with.  I like sewing people back up and feeling the immediate gratification, so I can only imagine the satisfaction that must come with opening up someone's heart and making it better.  But it's not worth spending a lifetime of not being able to take a break!  A few years back, one of our UCI surgeons had a heart attack during a super long surgery.  There was no one else who could take over, so he just had himself hooked up to a nitro IV and finished the surgery because he couldn't walk away and leave the patient flayed open on the table.  Now that's just craziness.  Admirable, certainly, but crazy nonetheless.

I find my boredom comforting because for a little while I thought surgery might sway me away from emergency medicine.  Switching to surgery as my specialty choice, however, would throw my life into a vortex, because every extracurricular activity I've done so far, my whole medical career foundation, revolves around emergency medicine.  Many ER doctors I know confessed to their utter boredom during their med school surgery rotations.  One, very near and dear to me and who shall remain unnamed - a certain Dr. P - fell asleep while he was holding a patient's chest open with the retractor!  So by being bored in surgeries sometimes, I know I'm on the right track.