Tuesday, May 17, 2011

Is There a Doctor in the House?

Last week, I had a kid-free weekend coming up. Trying to decide how to spend my time, I googled volunteer opportunities in Little Rock, AR. I came across a website called volunteermatch.com, or something like that, and signed in to look for opportunities.

There were lots of chances to mentor kids, or host exchange students, but I have two kids of my own that I am currently trying to mentor, so I am reluctant at this point to take any others on. It seemed serendipitous that a big event was happening on Saturday, called Take Steps for Crohn's and colitis. They were looking for 50 volunteers to help set up. My brother has Crohn's disease - he is in Boston. I decided to go for it. I e-mailed the coordinator, explaining that I was a physician and touting my personal interest in helping out. She e-mailed me back.

"We had a nurse running the First Aid tent, but she had to back out due to family obligations. Could you man the tent between three and seven o'clock?"

I cursed the fact that I told her I was a physician. I am a pathologist, for crying out loud. I could do someone's autopsy, if they died? I was counting on setting up tents, or maybe hanging up balloons, but running the First Aid tent? Yikes.

I decided well, maybe I'm a pathologist, but I'm also a mom. I don't keep up with my ACLS certification, but I am pretty good at bandaging boo-boos. I told her yes, and hurriedly and desperately recruited my friend Ramona Bates, a surgeon, to help.

Ramona and I arrived promptly at 3:00, and despite our attempts to help in whatever capacity, we were relegated to the First Aid tent. There was a plethora of Central High School students doing chalk art and any manual labor that was necessary. I was worried (Ramona was not), but my worries were to no avail. In four hours, we passed out two band-aids - to the same person - one who was trying to protect a blister during the walk. MEMS was present - it seemed a little silly considering the short walk required after the provision of massive amounts of Bar-B-Q, freebies, and pizza, but I was still comforted that if anyone needed a "real doctor," I had back-up in Ramona and MEMS.

As a pathologist, I worry about my little exposure to the "real world" of medicine. Here I am, a bona fide M.D., and what do I have to show for it? Sure, I make a decent living, and am proud of what I do, but why do I have heart palpitations when I am on an airplane and I worry about hearing an overhead announcement, "We have an emergency and we need a doctor - are there any on board?" Will I be able to perform? I was recently discussing this with an OB - she voiced the same concerns. She was on a plane recently where they asked for a doctor, and after realizing she was one of two on board - her and an ENT - they both reluctantly volunteered to help, wondering if they could do anything for a geriatric stroke victim.

I was talking with one of my partners Monday about my weekend volunteer experience. She empathized. She said, "I think we should have a yearly workshop. Call it, "Is There a Doctor in the House?" And we should be updated on how to respond, as M.D.'s, in emergency situations. We were trained to help, and we should keep up the training, so we can perform in these situations.

One Friday night a couple of years ago, I was triaging bone marrows and lymph nodes that were rolling in mercilessly while I was on weekend call. I had just finished a platelet apheresis on a patient with Essential Thrombocytosis. She had been done for a couple of hours, and for all I knew, she was on her way home. I got a call from the dialysis nurse. "She is on the floor, seizing." Shit. I told her to call the heme/onc. He was climbing a local mountain for exercise. I told her to call the on call hospitalist. He told her to call me. As I was rushing upstairs to get labs and try to stabilize her, with my limited microscope medicine, I got a call from an internal medicine doctor. "Her electrolytes are out of whack. We are fixing it. It is all under control."

We are so subspecialized, in medicine, that the very thing we start off trying to be good at (dealing with these emergency situations) we end up being abysmally afraid of. Maybe it is just pathology. I am a general pathologist. I presented three disseminated fungal infections at a hospital-wide Chest Conference today. I did three fine needle aspirations in fast-track ED. I handled two inpatient needles in radiology - making spur of the moment decisions with limited tissue to benefit the patient in the CT scan, under the needle. I feel like I am so much, but also not enough. Does anyone else feel this way, as a doctor?

27 comments:

  1. YES :)

    Even though I (unfortunately) deal with a lot of medical issues in my job like blood pressure or UTIs, I don't get called for any medical emergencies. The IM doctor who works on my floor always leaves early and I'm alone for the hour after she leaves. I spend that hour terrified, even though there's another IM doctor on the floor below us. So far, the biggest "emergency" has been verifying PICC placement on an X-ray, which I was reluctant to do b/c I hadn't done it in years. I asked the urologist on our floor to confirm, who first couldn't find the line on the film. When I pointed it out to him, he said it looked right, but none of that filled me with confidence.

    Dealing with emergencies is overrated though. I remember in my intern year, some of the medicine attendings were telling stories about volunteering their services in emergency situations. Their stories often ended with, "And that's why I'll never volunteer again."

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  2. I noticed you don't have an emergency physician among your list of MiMs - this is precisely why the field of emergency medicine developed and why I went into it. I am a jill-of-all trades and love it. So the airplane/medical tent scenarios won't have all the fancy equipment I'm used to or all the medicines in the world, I'd still volunteer (and still be scared because I rely on some of that stuff).

    Although you did give me a great business idea, a 2-day course, CME-approved (of course), how to simply manage diseases in real world settings: deliver a baby, MI, stroke, asthma attack. There would be an optional 3rd day where you could get BLS/ACLS re-certified in one day.

    PS. Always bring your cellphone. Nothing like an MD calling 911 to bring an ambulance faster.

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  3. YES. I am a pathologist, too, and oh, boy, do I dread the "Is there a doctor in the house?" I work in a larger, half-academic practice and focus almost entirely on surgical pathology, though- so I feel even more limited in what I can do. I don't do cytology, or any clinical path, and would have to do some serious brushing up to remember how to handle transfusion reactions, something that used to be so innate to me that I could (and maybe did) handle them in my sleep. I sometimes feel so inadequate in comparison to well-rounded general pathologists, much less 'real' doctors who can handle a true emergency with confidence.

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  4. This is exactly why I love being a veterinarian, though I work only on horses and am no longer comfortable with small animal emergencies. Horses, though... I have that covered, unless it's a dystocia or a foal. I hate therio.

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  5. Your idea for a course is such a good one. I think that most drs would be uncomfortable (except possibly EM drs) in these situations. Out in the field, you have no backup support and none of the equipment you're used to, and I'd imagine it would be tough to think of what to do for most people.

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  6. I hear you! I'm a dermatopathologist and read 100% dermpath. I definitely don't want to find myself in an emergency situation. I don't even like my family members asking me medical questions. Show me your rash or tumor or mole any day. But otherwise, I'm so subspecialized I'm completely useless.

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  7. your post reminded me of funny/embarassing story:

    As a first year endocrine fellow, i heard about a previous endocrine fellow + attending who were doing inpatient consult rounds. Apparently they walked into a patient's room and found her seizing, the endocrine attending ran out of the room yelling, "HELP! We need a doctor!".

    This story has been passed down through our fellows to remind us that in code situations, we can try to do a bit more than check a blood sugar!

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  8. We have a close family friend who is a anesthesiologist and everytime we are in the gym together he comments to me "I hope no one gets hurt and needs a doctor, the only thing I know how to do is put someone out!"

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  9. I was dancing chorus in a musical theater production many years ago when someone came running backstage yelling for me...the Director had collapsed on stage and nobody knew what was wrong. Apparently he was standing there in mid tirade (...is this the best you people can give me???) when he just keeled over.

    I came running thinking "what do I remember, what do I remember...". I had no sooner checked for a breathing and a pulse when another cast member came running - she was an ER nurse and I gratefully stepped back to do whatever she told me to do.

    Why did they call me? I was a Dentist and the closest thing that they had to a "Doctor in the house..."

    If he had needed an extraction or local anesthetic I would have been fine...

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  10. My sister is an OB/GYN and whenever extended family members come to here with medical questions she always replies with (even to the men), "Is this about your vagina, because that's all I do".

    One of our pathologists was on an international flight when the call came for a doctor, there was the pathologist and a radiologist on board which wasn't going to help the person having chest pains much. Luckily there was an ER nurse and an EMT on the same flight who also came forward.

    I think having a yearly review in the "Is There a Doctor in the House" basics is a great idea. I hope it catches on!

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  11. Gizabeth- Yes! I know exactly how you feel....although maybe worse? I actually practice Med-Peds, and while I am comfortable handling emergencies in the office/hospital, it is way different in the "real world." I think I should be helpful given my training and background, yet in reality, I am terrified. I say a silent prayer every time I fly- "1)Please let us have a safe flight. 2) Please let there be no inflight medical emergencies. Amen" I have experienced one flying emergency and learned that most airplanes have: a) no equipment except a bp cuff and b) bp cuff is not real helpful since airplanes are so noisy, you can't hear anything anyhow. I took a history, a pulse, BP by palp and gave the lady some juice. We made it to the airport and she did fine. I was very relieved and, bonus!, got upgraded to 1st class for the next leg of flight.

    Susan- I would love to attend that course! Great idea!

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  12. To all above - Fizzy, friend of anesthesia, dermpath, path, endocrine, vet, dentist, friend of OB, med-peds, Wow, thanks. I feel so much less awkward and alone.

    To Susan in agreement with Rock Star MD girl and others above - that course sounds fabulous, especially if cookies, I mean CME (and cookies) are involved!

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  13. Oh yes, as a pediatric suspecialist who is 80% basic research & practices at a very academic institution, I dread the inflight announcements since its almost 99% adult patients that do not have type 1 diabetes or short stature! My husband once pushed the button for me, telling me to go; thankfully there was a family med MD on board who got there first.

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  14. Yes, Susan, that would be a great course!

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  15. Maybe the should change it to "Is there an EMT/paramedic in the house?"

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  16. A comment from the other side of the desk...
    When I was 32 weeks pregnant with my now 20 month old daughter, I had crippling pain from hemorrhoids. Unfortunately I had never had them before, so wasn't sure that's what was going on. My OB's office told me to see my primary physician, even after a bleed while urinating left a toilet reddened with blood. My primary physician's office flatly refused to schedule an appointment because I was pregnant. My OB took pity on me and sent me to a surgeon, who drained a second thrombosed hemorrhoid and provided tremendous relief.

    Certainly in that case the high level of specialization caused considerable trouble for the patient.

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  17. Gizabeth - I think its pretty awesome that you wanted to spend your free weekend giving back! I know it wasn't the point of the post, but I feel inspired to volunteer more!

    Also, I like the idea of a course on emergencies. The fear of being the doctor on the plane or at the scene of some terrible accident seems to be pretty common - even if you're used to dealing with a range of issues, few people are used to dealing with them with no supplies!!

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  18. We all need to keep our ACLS current. It helps a lot. Some cardiologists I work with dont even know the current ratio of breaths to compressions. The goal is to keep patient alive until 911 gets there. Use common sense. The CME course idea is a nice one

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  19. I was recently on a flight to a conference with many other doctors on board. If there were to have been a call for a doctor (there wasn't), there would be no shortage of docs on this flight!

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  20. I'm also impressed that you wanted to spend your free weekend volunteering! My train of thought would have been, "How late can I sleep, how far can I run, and how many novels can I read?" :)

    This is not quite the same situation :) but I was on the way home from a shelter a few weeks ago where I'd spent the day doing surgery (so I was in scrubs) and I stopped because I saw a dog in the street who'd been hit by a car. She was a big pit bull, she could move but couldn't really stand so I assumed she was in pain, she didn't have any tags so I wasn't sure if she'd been vaccinated for rabies, and it was a bad part of town where a lot of people have fighting dogs. My entire contribution to the situation was suggesting we use a board to lift her to protect her spine (since the police officer and guy who hit her were planning to sling her into the pickup bed by her rear legs and collar) and then taking the guy who hit her to Animal Control where the vet could assess her.

    Granted, I'm not sure how much more I could have done, since I didn't want to have my arm bitten off by a strange dog who was in severe pain, but I also felt like the guy who hit her and the police officers who arrived after I stopped were all waiting for me to tell them what to do, and it freaked me out.

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  21. And here I thought it was just us psychiatrists!

    Thanks for an excellent post.

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  22. Ana - glad you had back-up!

    Brit - GREAT suggestion.

    anon@3:21 - sorry for your troubles! You definitely want an experienced person to deal with your problem, even if it takes some time to find one.

    Thanks Cutter and Life in Vet School. I'm hoping to find some outdoor work in the future. That dog situation sounds pretty scary - glad you were able to help out. What an interesting alt-perspective on medicine.

    Agree, Cardiomom. Ramona is ACLS certified. Most pathologists I know don't keep it up. I really should.

    Anon@6:28 - hope the docs were more comfortable than me in emergency situations.

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  23. Anon @ 10:19 - Nice for us docs to be able to bond in our own incompetence, right? As long as we celebrate all that we are doing, of course.

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  24. Great post!
    One of my colleagues (she's adult endocrine) had a young man passed out on a flight one time. She put in an IV and gave him lactated ringer's! They had some really great supplies.
    One of my peds colleagues delivered a baby on the plane.
    Also, I don't think ACLS is all that necessary, unless you work in a hospital. Otherwise, BLS is really all you need. I renewed my ACLS and PALS recently only to find out my clinic has no crash cart or meds of any kind, so really all I can do is BLS stuff.

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  25. And then sometimes you just happen to be in the right place at the right time, even if you are a primary care pediatrician on a plane... http://archpedi.ama-assn.org/cgi/content/full/164/8/694

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  26. I think this is a common concern. I was recently reading Every Patient Tells a Story and it talks a lot about the death of the physical exam and the fact that many physicians aren't competent in the basics of medicine after training ends. It is an interesting read.

    Great idea to have a refresher course for those things!

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  27. Hey everyone, this course already exists!

    http://www.onboardme.com/
    It's run by the wonderful Drs. Anna Carvalho and Vincent Poirier (full disclosure--Anna and I did residency at the same time, with her in the 5-year ER program and continuing to specialize in aviation medicine. She's smart and funny, "toute le kit," as we say in Montreal).

    You get to play with a simulator and everyone. One of my other emerg doc friends took the course and enjoyed the slide/raft.

    I'm an emergency doc and have done 3 on-flight calls, none of them life-threatening. My first was just after med school and I probably shouldn't have stood up because I didn't have malpractice coverage between med school and residency. But otherwise, I think your four years of med school are still vastly better training than a St. John's ambulance course here or there.

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