Monday, February 15, 2010

Re-post -- Medical Bloggers: Touche Pas A Mon Pote!

J'ai passé une nuit blanche... during which I found myself missing Nurse K and her now defunct blog, CrassPollination. I hope that it, like the Phoenix, will rise from the ashes, or at least become available in some other format. Ummm, like a book -- that'd be cool.

Anyway, that led to laughing at my various references to her fine anecdotes, and my virgin shock at the âpre, biting depictions of the dread Problem Patients and the manner in which the well-raised, polite ED nurse reacts to them.

I don't know exactly why my dander was all up, back in November of 2008. By then, I had had the second of six surgeries, was not able to sleep at all (to the point of true toxicity), and was in the kind of pain that births dreams of loaded guns. I also had really just started to read medical blogs with any sort of attention. Okay, yes, I also had begun to hear the dreaded "ewww, you're a complicated patient, aren't you?" Add to that that I was a licensed, charter member of the Annoying Chronic Paineurs, and yeah, I might have been a tad bit touchy.

A hard time, to be sure, but I'm not the kind of person to project my issues onto someone else.


Anyway, when I am feeling all righteous and stern, these medicos piss me off. When I am thinking straight? I am oh-so-grateful for each and every one.

*In deference to my broken leg, I am not going to make my damned fingers waltz around to see if the links in this repost remain in effect, and accurate. Do it your own self!


"Touche pas..." has long been a favorite saying (and message) of mine. Indeed, I've always wanted the T-shirt. But how to explain to someone unfamiliar with both the situation and the language what it means? I had never googled it -- oh, the amazing act of googling! Anyway, I found this short passage, which does a pretty nice job of it (though the lack of an accent puzzles me -- why get something almost right?):

A Powerful Political/Social Sign: "touche pas a mon pote"
One of my favorite social-change campaigns of all time came to my attention recently when I saw it in the background of a film shot in Paris.

It's the ubiquitous yellow hand of the French anti-racisim organization SOS Racisme, which travels the French visual landscape coupled with the phrase "touche pas a mon pote," which translates roughly as "don't mess with my buddy."

The straight-ahead everyday slang of the phrase in French --- it's literally what one would say in a street confrontation --- and the powerful yellow hand have always been a model for me of really understanding both the potential audience for a social change initiative and the moment of decision the designer/strategist is trying to influence. This is what you say to protect a friend, and the implied strength-in-numbers and the sense that "we are watching you" and holding you up to social shame makes the slogan an absolutely brilliant piece of writing.

In an earlier post I quoted science writer Daniel Goleman on research showing that the more someone is perceived to be "like me" the more our empathic brain circuits are activated.

My name is Retired Educator, and I am addicted to medical blogs. (Hi, Retired Educator!)

I am one of those barely-there people. If you sneak a peek behind La Belle Bianca Castafiore's considerable operatic girth, there I am, ensconced in this drafty, ancient manor with my darling, but essentially clueless, Fred, and with the real brains behind the outfit -- the Felines.

Once upon a time, I was -- sniff -- a rising star; More importantly, I had considerable fame as a clothes hound and shoe afficianado. Chronic illness and pretty severe daily pain has reduced me to unknown status, and my wardrobe to oversized organic cottons, with the occasional silk and linen blend, all bearing the satanic marks of elastic and screeching velcro closures.

Sleeping became difficult, and it is not an exaggeration to say that the rising sun became an emblem of survival. The computer, and its incredible access to almost anything one can dream up, was a great tool to wield in the middle of those long nights. I was a member of several online communities of people who were also in pain, who were suffering from the same acronyms. Boy... was that depressing.

One 3 am (apparently, the witching hour), I was searching for information on a medical test that I was about to undergo -- something that doctors just adore -- and my googling returned a hit that turned out to be transformative. I had never before ventured into the blogosphere, thinking it a "place" for only the Smarmiest of Smarty Pants. I was ill-prepared for the pleasant shock of reading this acerbic nurse's blog. It beat the hell out of the navel-gazing and shrill cheerleading of the online support groups.

And so it was that Nurse K's blog, Crass-Pollination: An ER blog (ED if you're... oh, never mind), was the first medical blog I ever read. Medical blogs helped me get through some of the long nights that were already medically oriented, anyway -- and intense. It's much better to laugh than to cry -- and infinitely better to snort-laugh than to weakly titter. Nurse K supplied lots of those snorts, although I now regularly read a good dozen other medical blogs that are equally entertaining and informing.

These medicos are intelligent and creative people, turns out. For whatever reason, blogs maintained by Other Liberal Educators proved... unsatisfying. And so, I was hooked.

I never expected to learn some of the things that I have, however -- mostly things pertaining to intense professional frustration. There are a host of other nominatives that I sometimes would like to apply but won't. Probably. Well, maybe. We'll see. As I said way back in the beginning, whose blog is it anyway? That snappy-snippy attitude, and that respect, is due every blogger. Well, not every blogger. Well, maybe. We'll see. Cela dépend.

(Please recall: I am the prof who declares that "Yes, there *are* stupid questions, just as there *are* stupid students. That said, I never doubt my own ability to salvage all students and most questions. It is called getting to the heart of the matter.)

It turns out that learning what particularly challenges [blogging] nurses, doctors, and other health-related workers has impacted my interactions with those self-same people in my life. In some ways, it has been marvelously helpful -- mostly, it encourages me not to blather on and on, as I tend to do when not feeling well. I need to be an efficient, honest, and straightforward patient, since I expect as much from the people trying to help me. I now don't provide much in the way of information that is not pertinent to whatever the specific situation might be, and I do not ask for things that I might have in the past (mostly creature comforts -- a blanket, a pillow -- but also that meal that never came, or the medication that never arrived).

Unfortunately, the thing I learned most was fear of these people. Before anyone flies into some sort of fury-driven arrhythmia, let me qualify that use of the word "fear." It is the same fear that I experience when driving near speeding, lane-hogging, long distance rigs on the highway-- and it feels like a prudent response.

These [blogging] doctors, nurses, et al, are not malevolent, and they would not purposefully hurt anyone in a lasting way. I believe, however, that a small minority *does* intentionally inflict temporary pain -- they confess it, and they confess it with a certain amount of very disturbing pride. Of course, there will be a complete disavowal -- instead, my lack of humor will be suspect, or my intellect (more likely my worldliness, or common sense, saying, "Jane, you ignorant slut," to which I can only say, "Dan, you pompous ass...") Shoot, we all recognize the urge and understand it -- but acting on it? Oh, what are the words? Hmmm. Oh, yes: wrong and amoral. Criminal?

Faced with an annoying waste of time that is a woman faking a seizure, the response is:
I head to the cabinet that holds the STAT 16 Fr Punitive Foley Catheter, and Nurse Tinkerbell heads for the cabinet that holds the STAT 16g Punitive IV Catheter.It's called a "16 Squared", and it's the first line treatment for ODs and fake seizures.

[The whole entry itself is totally hilarious, and I am a great fan of this particular blog.]

The punitive foley and i.v. catheter are tame examples, really. Maybe what is most disturbing is that I have no difficulty believing that this sort of thing, and worse, happens. I guess it is not supposed to matter because no lasting damage is done, or the patient is presumed too stupid or "crayzee" to ever know.

And, it must be said, in this election time, that there are systemic cruelties that no human can match -- the idiotic aspects of EMTALA law, the medication too expensive to be had, the follow-up care that just won't happen, the dumping that has never really stopped (go ahead, challenge me on that, I dare you. I double-dare you. I will name names!).

Abuses? Good God, I don't know how health care professionals (I am thinking primarily of the ER/ED environment) maintain any semblance of a good attitude in the face of all the social ills that masquerade as physical or mental health emergencies. I imagine that almost everyone they see is at least a dual diagnosis. Despite this terrible complexity, they are called on to treat the presenting symptoms, the presenting problem -- but the background of addiction or some other chronic disease invariably creeps in to complicate the visit. It takes a lot of disciplined skill to keep the "emergency" visit on an "emergency" track.

In the blogs about emergency medicine, you will read stories of women wanting pregnancy tests or ultrasounds at 3 am -- after arriving via ambulance, no less -- and tales of homeless people who want something to eat (a sammich) and a place to sleep. Drug-seekers are an enormous drag on the general goodwill and dealing with them daily may well be enough to tarnish even the finest of attitudes. These folks are usually allergic to all medicine except opiates, and attempt to steer their treatment straight toward the drug they desire. WhiteCoat, who rants at another insightful and entertaining blog spot, tells a story respectful of all comers: "Drug Seekers Suck." There are *countless* number of blogged posts generated by the frustration of dealing with drug-seekers -- would that that provided something beyond temporary catharsis.

Most professionals worth their salt know frustration -- if they don't, they've chosen a niche of safety, more power to them. What said professional chooses to do with that frustration, however, speaks volumes.

Moi? In the built-in cabinets of the Ivory Tower, I kept a stash of amazing weaponry to throw at students, although chalk would always do, in a pinch. I converted every departmental or university-wide insanity into a reactive act of pique, usually in the form of a scathing letter -- or, if the matter were truly weighty, a collective effort with colleagues. Maybe a sit-in, or a huffy petition. When the problems were "emergent," so was my response. When the issues were more some systemic form of illness, working toward a cure required much, required deep study, required patience. Of course, I understand that an academic or intellectual emergency does not really matter, in that grand scheme of things, in, cough, the order of things. Except for two specific instances*, life itself was never in question -- although divestiture from South Africa did seem to matter... Blogging medical professionals, par contre, exist within a world of pain walled off from the rest of us. Not unlike an abscess. (Sorry, that came unbidden! But, really, how true! A good incision and drainage might be just what a doctor might order...)

And like the whining teenager, there's no way [we] could ever understand.

It must be very wearing to deal with the people who are inappropriately demanding the considerable medical talents of an emergency department. You don't have to follow many medical blogs before the problem list is set: people on Medicaid, the uninsured, drug-seekers, people with chronic pain, fibromyalgia, headache, homeless people, alcoholics, addicts, and general dirtbags who don't appear sufficiently grateful for the ministrations received. Just looking at the list is enough to make *me* sigh with anticipated fatigue and frustration. What can I say? I am a real fan of the genre and of the brave people driving the narration.

Then, it happened. Nurse K put me on the list. Oy! There it was: reflex sympathetic dystrophy (the inaccuracy of the name continues to be perpetuated by both sufferers and medicos alike -- nevermind that sympathetically maintained pain is not necessary to the condition, or that it does not include causalgia -- because CRPS is just too unwieldy to say!)

Anyway, this is the entrapment post in question:

52 y.o. female with a past medical history of something like:
Fibromyalgia, chronic pain in other conditions, anxiety, depression, panic disorder, bipolar II, hyperventilation syndrome, cyclical vomiting, restless leg syndrome, reflex sympathetic dystrophy,IBS, endometriosis, L4-L5 "bulging disk", bunionectomy
CABG 6 months ago....

...presents with "chest tightening". In the last month alone, she's had five negative chest-related work-ups including a clear cardiac cath.

Geez, Crayzee, why'd you have to have that CABG on there? Now we have to treat you like a real patient.

As part of the banter that appeared in the comment section following the post, Nurse K had occasion to write: I think all crayzee, anxiety-mediated diseases and "pain out of proportion to exam" complaints should just be lumped together under this ICD-9 code.

I often wondered how people with fibromyalgia felt when they were under attack. Now I was in the same position, and it pissed me off.

For all of five minutes! For what use is anger in the face of ignorance? And since stamping and stomping ouT ignorance has been the calling of my life... surely this would qualify as one of those euphemistic "teaching opportunities"!

Well, no. I don't have the energy or -- after that terribly uncomfortable aforementioned five minutes -- the desire. No, once again I come away convinced that these people are dangerous (and I hear the explanatory retort of 'we are just venting... we're professionals but we are also only human... we'd never say these things to patients or act on them...').

How much do you think it would blow these med bloggers minds to learn that they are teaching the public to second guess and seriously doubt their capacity for satisfactory treatment and diagnosis?

Of course it must be reiterated that the offending, offensive bloggers are a small minority, and I wish I were less thin-skinned, more able to "consider the source." Shoot -- it is illuminating just to remember the traits likely to a blogger to begin with! There is a need to be right, a desire to pontificate, a hope to be known -- just as there is knowledge to share, experiences to detail, and much fun to be had. And so it is that I remain enamoured of these talented people and the incredible tales of humanity they have to share, and wish the medical bloggers the best.

But always remember, and never forget: Touche pas à mon pote!

*Two students of mine, both Freshmen, turned in suicide notes as homework, and in so doing, cemented my rapid-turnover grading habit forever. Thankfully, both students lived; Sadly, they both had to drop out of college, though I am sure they returned -- both were phenomenally gifted.

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