The Waiting Game

by: DocStory

Mon Aug 15, 2011 at 23:45:29 PM PDT

First patient of the day: Woke up with decreased hearing in one ear and since she's a musician, she was pretty concerned.  The ears looked normal.  No problem, refer to ENT (the ear/nose/throat doc) this week.

Next paitent: Worsening back pain that radiates down the leg.  She had an injury last year and since then, she's been dealing with this on and off pain and now wants to know what's wrong and can it be cured.  Neurological exam was normal, thus not an emergency.  Pain medications prescribed, MRI ordered to be done next week and follow up with an Orthopedic surgeon, a Spine Specialist to boot, to be seen after the MRI is done.   She obviously has a slipped disc, but I wanted to see how severe it was and see if the Spine Specialist would recommend any procedures.

Another patient the same day: Had blood in his ear and because he had perforated ear drums in the past, he wanted to make sure he didn't have another one.  Nope, ear drum good. Small laceration in the canal, “but call your ENT so she can evaluate you this week and knows what's going on.”

Ahhhhh, the feel of working with insured patients!  You see, I moonlight at a private practice's urgent care where it's clients all have great coverage.  Need a study? No problem.  A specialist? How does next week sound?  There's nothing like being a doctor and being able to provide the medical care that a patient needs!  But that's not how it is for the uninsured.

In working a my community clinic for the uninsured, it's a completely different story. One patient I saw had anemia.  As I looked through the chart, he had 3 positive stool cards (that screen for colon cancer) in December 2009.  I looked at him, “Have you had a colonoscopy yet?” as I looked to compare his previous weights and see he had lost 15 pounds in the last 6 months. “Nope.” I then see in the referral section of his chart that he had been referred for colonoscopy in December, 2009.  When I asked for the status of the referral from the referral coordinator, “Still Pending.” I just shook my head.  Since I used to work at one of the County Hospitals, I have some tricks to getting patients in.  I called the back line for the Endoscopy Suite and asked to speak with one of the fellows.  I tell him the story. “Send him to the Emergency Room.” “But he's stable, he just needs an urgent colonoscopy.” “No such thing.”  I just remained quiet on the phone.  “All right, give me his name and number and I'll try to get him in within a month.”  So I gave him all the appropriate information and also got the fellow's name and pager number...a little accountability and of course, promised to name my first born child after him...not really, but it felt like that.

Another patient I saw had tore her biceps tendon 1 ½ years ago.  “I'm still waiting to see Orthopedics,” she laments.  Are you kidding me? Again, I check the status...”Still Pending.”  I sigh as I examine her atrophied biceps muscle.  Now I would have sent her to the county emergency room had I seen her from the get go knowing that it takes over a year to get an Orthopedics appointment at county.  In sending patients to the emergency room, I tell them, “You'll wait 24-36 hours to been seen, but if it's serious enough, you'll see an Orthopedist in the ER, but at the very least the ER will refer you to see Orthopedics at their clinic within a few weeks.  Starting to see why the ERs are so outlandishly crowded?  Orthopedics is a special case, because there is not one Orthopedic Surgeon that will take MediCal.  So even when a patient has MediCal...all orthopedic problems must go through the county.

A couple months ago, I saw a man in his 40's that had what seemed like an enlarged lymph node on one side.  Is was about grape sized, but had been there for about 2 years.  Not a smoker or drinker (increase one's risk for head and neck cancer), so I ordered a tuberculosis test and referred him to ENT knowing that it was about a 6 month wait.  He came back in one month...TB test negative, but now the mass was the size of a golf ball and rock hard...sounds bad!  So....the speech..”Ok, so I'm going to send you to the ER because you can't wait any longer for a biopsy and they are the only ones that can get you into ENT within a week.  You'll wait 24-36 hours, so bring a coat, food, a book and just be patient.  Seeing a pattern here?

Last week I saw a 30 something year old man who came in because he had an inguinal hernia for a couple of years.  He wanted surgery.  Yup, he had an avocado-sized hernia.  But it wasn't an emergency.  “I'll refer you to surgery, but it will take 6-9 months to get an appointment.  Then it will take 1-2 years before you get the actual surgery.”

Truly, I can't imagine having to wait so long for my health care.  Now some people say, “You see, if we have Universal Health Care, this is what it will be like.  It will be like the county.”  But that's not correct.  You see, the county isn't providing “universal health care”.  It provides Safety Net care.  Big difference!  Safety net care tries to pick up the slack in providing health care to its residents who otherwise couldn't get any health care at all except truly emergent care.  And even emergent care wasn't always available for the uninsured.  It took a group a young doctors in training in the 80's who noticed that when patients were being transferred from private hospitals to public hospitals for emergent conditions, they would arrive dead!  Thus the EMTALA law makes it mandatory for every emergency room to attend to every patient that crosses their threshold irrespective of ability to pay and provide emergent and hospital care if needed.

Let me give you an example of a sort of Universal Health Care that the U.S. provides. Prenatal and Maternity Care. Before the 90's, if a pregnant woman didn't have medical insurance they were required to deliver at the county hospitals.  I started my training at a county hospital in the mid 90's and thus I remember stories of how it “used to be”...deliveries in the hallways because it was so overcrowded.  The NICUs (Neonatal Intensive Care Unit) packed with premature and sick infants because there was no prenatal care to be had.  And then we decided that this type of care was intolerable and thus now all pregnant women without insurance are given MediCal and low and behold...the county delivery rooms are pretty quiet.  The NICUs are empty.  Women are getting prenatal care delivering at UCLA, Cedar-Sinai, whatever hospital they choose basically.  Obstetrical mortality is lower; infant mortality is lower.  The hospitals are happy because they're getting paid to attend to these patients.  No where in LA is there a wait list to get prenatal care or overcrowded delivery rooms.  You see, there's plenty of providers and hospitals to take care of these patients.  The providers and hospitals are happy.  The patients are healthy.  Win win.

living with ptsd

by: la_moreno

Wed Jun 22, 2011 at 09:36:24 AM PDT

My sister wrote to me the other day, from the side of a two-lane desert highway.  She was driving through the wildfire-filled canyons on her way home from a memorial service in another rural town nearby.  At the service, she'd seen one of our siblings, our mother, our step-mother and a host of elders from our growing-up years.  She called me a bit later, just getting through the ravages of an anxiety attack. She had pulled over when it became clear the panic was coming on and she had taken a xanax and was sitting, waiting for the wave to crest and subside enough that she could continue her drive home.  Although the threats posed by the fires, the sadness of the memorial and the ever-present parental tension navigations were formidable, what my sister was experiencing - and it's an on-going experience that she and I share - was not just a response to all of those; it was a flare up of older wounds, re-activated.  It was Post-traumatic stress disorder (PTSD).

After living this far, I have come to realize and recognize that many people around me live with PTSD or some form of anxiety or acute stress disorder.  It is especially common among my friends and colleagues of color, who, like me for most of my life, don't realize we have it or realize the ways it affects every aspect of our lives. 

The hallmark "symptomology" includes physiological responses, such as flashbacks, anxiety attacks, hyper-vigilance for any real or perceived threats, and although there are many resources available about those in general, through doctors, libraries, on the Internets, we really don't have a way of talking about the way we live day-to-day with trauma.  Beyond some writings by combat veterans and survivors of physical and sexual abuse, who commonly live with PTSD, and outside of some incredible writing and a body of research by Indigenous scholars and intellectuals, there is not a lot of information available to us, as people of color, about the ways that living with trauma wounds affects us.  There are different kinds of trauma including complex, generational, historical.  Sometimes it comes from a one-time situation, like a mugging or being in the path of a tornado; sometimes it comes from living in a constant state of oppression and grief.  And it affects every part of who we are, from our spirituality and connectedness with our own divinity, to the ways we work, love others and how we see the world.  It is silent but present in most of our daily lives and often plays a recurring role in dreamlife.  It interconnects with life challenges around intimacy, personal achievement, addiction, emotional and mental health, sexuality, education, interpersonal communications, career choices and violence.  I feel absolutely certain that if you surveyed everyone in a given prison or substance abuse treatment center, the vast majority of people there would have some form of PTSD.  But don't imagine for a moment the same would not be true if you surveyed everyone at the NYC Ballet, in the L.A. County Museum of Art, Sunday at the park in Atlanta, GA, at the Iowa State Fair, in line at the motor vehicle department in Anytown, USA. 

I find myself wondering why there is not more of an organized response to living with PTSD, especially among social justice folks.  Outside of veteran's, there is no real public or health education campaign that I know of that addresses this phenomenon within a particular part of our population.  Even medi-pharma folks have not found a way to make bank off of this volume of people (although they surely do off of incomplete or mis-diagnoses).  Why is that? Do we all call what the medical psych and millitary industrial complexes call our experience with trauma?  

My sister and I, who remain extremely close as we've entered our 40's, have had vastly different experiences as adults.  We relate in very different ways to the wounds we carry.  But we are and have always been able to talk and confide in one another about our memories and struggles and about our progress.  Sometimes that is just being able to tread water for a while instead of drowning. Don't get me wrong - for some reason, I am never waylaid for long by my ptsd.  I am intensely motivated to address it through different therapeutic modalities and have luckily never been thrown into clinical depression or more than a few days of feeling paralyzed.  But part of PTSD is that sometimes, when the tensions are highest, your limbic system tells you to flee as fast as you can. That can be extremely unsettling and also pretty inconvenient for a time, especially in the midst of work, loving and life in general.

I'm lucky enough to have found and pieced together over the last 20 years a wide-spectrum way of not only living with my PTSD, but actually being able to heal quite a lot of it (measuring my responses to stress-inducing situations now vs. 15 and 20 years ago).  But it is not gone.  It often flares up at the least convenient times and sends me, humbly, back to square one. In addition to talk therapy, I have found success in managing flare-ups through meditation, yoga and other exercise and by striving for nutritional balance. I've done limpias and sweats and done herbal tinctures and cleanses. Acupuncture and long soaks in a tub. PTSD affects each one of us differently, and so of course what works for one person may be different from what works for another, and what works can vary from situation to situation. Sadly, so many people don't realize they live with PTSD, and so they can't  even begin to address the source of so many challenges. My personal experience is that most doctors mistake PTSD for other things.  Obviously, that health education campaign I mentioned earlier should definitely have a component that's focused on all manner of health care providers, but it also needs to focus distinctly on teachers and parents and whatever groups are working with people of color communities, who are likely, due to a slew of isms and oppressions that affect us every day, to live with complex traumas every day.

Spirit or sweet serendipity brought me recently back into a closer orbit with a friend I had made almost 15 years ago, someone who works with survivors of sexual assault and who is herself a survivor.  She and her mother, a life-long activist from the pueblos of northern NM, have been working for 20 years to help their Native community and others to address sexual violence, alcoholism and suicide there.  Their work and the work of other Native scholars, intellectuals and activists, focuses on an analysis with trauma at its center.  It breaks down generational and complex traumas and shows us that each generation is inheriting their fore-mothers' and -fathers' trauma wounds, compounding their own.  When I look at my family histories - from Mexico and Lebanon and rural Arizona - I find endless amounts of intensely traumatic incidents my ancestors lived through...things like witnessing martyring at the stake, colonial conquest, religious persecution, rape, transnational adoption, living through the Great Depression in a box car...and that's just what I can find.  What about their day-to-day lives? I'm sure there's much more, buried.  I can, quite literally, feel it. 

Can you feel it?  Where do you feel or see the manifestations of traumatic experience in your life, in your family, community, in the world?

I'm heading to a conference soon, where I will be helping to facilitate a workshop on trauma in communities of color.  It's not to hold up any model or approach, but rather to start a conversation among activists and organizers, to ask them as I ask myself to really consider how we, as people of color, can begin to build awareness of how PTSD affects us.  I'll let you know how it goes.  I am not talking about creating victimhood here, but about looking at our resillience as people.  I'm talking about holding up all the ways we manage to survive and thrive in the face of this intensely personal, usually invisible presence that's with us always, on top of all of the mind-boggling challenges we live through every day as people of color, as women, as queer and trans folks. 

I'm talking about calling it out and naming it in our own terms and learning how to see and been seen. I'm talking about learning what works for us as individuals and in community.  And learning, every one of us, how to grow and blossom.

We're all driving through canyons in this life (not in a gas-guzzler in this vision), with fires all around us sometimes.  And we all need a roadside plan for ourselves, and a way to stop and breathe and see the world beyond the flares.

Nightingale Midwifery Clinic grand opening

by: los anjalis

Mon Jun 20, 2011 at 23:34:03 PM PDT

**************************************************

Nightingale Midwifery Clinic

...Offering affordable prenatal and postpartum care for you and your baby, including well woman care and classes.

1st and 3rd Tuesday of every month, 4:00-7:00pm

No insurance needed, $10-$20 sliding scale, Medicaid and some private insurance accepted.

Always safe, confidential care and plenty of time for questions and concerns.

For more info call: 505.510.1138. Walk-ins Welcome

Tuesday, June 21 · 4:00pm - 7:00pm

Albuquerque Birth Center

123 Wellesley SE

Albuquerque, New Mexico

******************************************************

Hello Friends and Allies-

After many years of conversations and planning, we are excited to announce the grand opening of the Nightingale Midwifery Clinic. We believe that all women in New Mexico deserve safe, respectful and confidential care during their pregnancies, labor, and postpartum period. We know that some women in New Mexico face great barriers to care, our midwifery clinic is designed to provide competent care in a dignified way, to women that may not otherwise access pregnancy services.

According to Deadly delivery: The maternal health care crisis in the USA, an Amnesty International report published in March 2010, "Women of color are less likely to have access to adequate maternal health care services. Native American and Alaska Native women are 3.6 times, African-American women 2.6 times and Latina women 2.5 times as likely as white women to receive late or no prenatal care....Women who do not receive prenatal care are three to four times more likely to die of pregnancy-related complications than women who do. Those with high-risk pregnancies are 5.3 times more likely to die if they do not receive prenatal care". This report goes on to explain that when women are able to access care, "Women of color are more likely to experience discriminatory and inappropriate treatment and poorer quality of care".

In New Mexico, we know that many women and families don't have health care coverage. We know that many women and families in our immigrant communities can't access health care because of their immigration status. We know many women and families are criminalized because of their struggles with substance use. We know that many teen parents are stigmatized in their decision to raise a family at a young age. We know that for many women and families, there exist very real obstacles that keep pregnant women from receiving appropriate care.

We know that for all these women and families, prenatal care is a human right. Join us in opening the Nightingale Midwifery Clinic, as we work to improve the health of all New Mexicans.

patient? consumer? client? i'm still uncomfortable.

by: los anjalis

Wed Apr 20, 2011 at 22:19:51 PM PDT

The word "patient" has never sat with me comfortably.  It can easily imply or carry an unintended power differential.  It transforms into an intended power differential in many cases.  It feels diminuitive at times.  And ownership-py, especially when preceded by "My".  My patient this or that.

But I use it when discussing my medical care, because the other prevalent terms, client and consumer, don't feel right either.  For the reasons Paul Krugman mentions below (there's a reason his NYTimes column is called "The Conscience of a Liberal."): 

April 20, 2011, 6:31 pm

Patients Are Not Consumers

I keep encountering discussions of health economics in which patients are referred to as “consumers”, after which the usual mantra of freedom of choice is invoked on behalf of voucherizing Medicare, or whatever.

We used to know better than this.

Medical care is an area in which crucial decisions — life and death decisions — must be made; yet making those decisions intelligently requires a vast amount of specialized knowledge; and often those decisions must also be made under conditions in which the patient is incapacitated, under severe stress, or needs action immediately, with no time for discussion, let alone comparison shopping.

That’s why we have medical ethics. That’s why doctors have traditionally both been viewed as something special and been expected to behave according to higher standards than the average professional. There’s a reason we have TV series about heroic doctors, while we don’t have TV series about heroic middle managers or heroic economists.

The idea that all this can be reduced to money — that doctors are just people selling services to consumers of health care — is, well, sickening. And the prevalence of this kind of language is a sign that something has gone very wrong not just with this discussion, but with our society’s values.

Thank you, Mr Krugman.

I must disagree about one thing -- tv shows revolving around heroic doctors. That's another kind of consumerism and superman-ism that we don't really need more of.

What do you think?  What do you call people you provide care for, if you're a healthcare provider, if you're a healer?  What do you want to be called, if you're on the other end of things?  What does a partnership, or empowered dynamic, look like, in regards to language?

Pap Smears at Walgreens! Colbert cracks us (and himself) up

by: los anjalis

Tue Apr 12, 2011 at 22:24:55 PM PDT

Healthcare Vs Healing

by: adriennemaree

Tue Mar 01, 2011 at 15:16:09 PM PST

last week i hurt my knee while i was in ny. i've had issues with my knees in the past - thickness impacts if you know what i mean. i'm working on it.

anyway, while helping our hostess, the elegant super fabulous dj rimarkable, with some groceries for a gig she was catering (she's the pam the funkstress of the east), i slipped on a patch of ice. i thought i was fine, but within a few hours my leg was swollen, hurting, my back felt lopsided and like it might have a knife in it, and i could hardly walk.

a breakdancer friend hooked me up with her doctor, but he was busy that day, so sent me to an orthopedic immediate care unit. and the immediate care unit did everything but touch my knee and actually figure out what was wrong with it. i told them all i knew, that it felt twisted or sprained - not broken. i told them i just needed some pain relief, some guidelines on how to not make it worse. they gave me an ultrasound, an x-ray, and some percoset (with a brief reference to constipation and drowsiness, bad combo...).

it amazed me to sit with health professionals who clearly cared and wanted to help, but didn't even examine my injury over the 5 hours i was with them.

the next night i went to see dj rimarkable spin and chairdanced all night. at the end of the night a woman who had actually held it down on the dance floor asked what was up, and i explained about my knee. she said - i am an acupuncturist, and i can do something about that.

the next day i met her at the brooklyn acupuncture project and she physically examined my knee, tracing all the rivers of pain flowing up and down my leg and back. and then she pinned me from head to toe.

after about 15 minutes, i felt a release in my back that led me to giggle. after another half hour, as i was drifting in that magical sleep that comes with acupuncture, i felt a massive boom through my whole body which rachel the acupuncturist told me was a chi boom, and a good thing. after she pulled out the needles, she rubbed an analgesic oil on my knee and said it was better than ice, which can put a chill into the joint that keeps it from healing. an hour after i walked in feeling broken, i walked out feeling aligned and healed, barely limping.

when i got home i went to the detroit community acupuncture clinic and got another treatment with nora, who also hooked me up with some kind of magical tiger balm patches to keep on my joints.

i just facilitated the whole weekend and could actively feel my body attending to itself, healing faster than i ever have from a knee (or ankle, or back) injury.

it felt like the exclamation mark on a train of thought i've been having - i want to always choose the traditional healing methods, the methods that rely on touch and turning the body's healing properties on itself.

and i have to remember that, even in emergencies, when it feels like the ER is the best move. i don't need health systems that start off asking about my insurance and give me the most expensive tests they have without leaving me in better condition.

i need healing.

love smells like fresh baked bread

by: poppyseed

Tue Feb 22, 2011 at 00:00:00 AM PST

it was catered. by the nursing home. i had the tuna sandwich. but it was mark who had actually seen the daughter in the er. he was the one who knew where she worked.

there is a guy whose job it is to drive from nursing home to nursing home telling people what to write so that when the family shows up again their inevitable lawsuit will be less likely to succeed. he has a PhD in philosophy.

and downstairs, i can't remember the room number, there is a tiny old woman with a tube in her nose and both hands tied to the bed. and every time i check on her she never looks me in the eye. she takes one look up and down, sets her teeth, and points her chin away from me as far as it will go. i don't think she likes me.

on her favorite pillow with my husband stroking her hair

by: poppyseed

Mon Jan 31, 2011 at 22:47:55 PM PST

i held her hand for an hour and a half while we were waiting for respiratory therapy. there was a code and one of the icu players had to get to the mri scanner and, frankly, the hospital isn't all that plentifully staffed in the first place, so we weren't exactly first priority.

but the thing is that i had to wake her up to tell her that she had cancer and she didn't want her family to see her get her tube out because that can get messy. but i'm getting ahead of myself.

Doing the Right Thing - Lab Tests for Everybody

by: jdwolverton

Fri Dec 10, 2010 at 06:15:27 AM PST

gasping

by: poppyseed

Thu Nov 25, 2010 at 00:00:00 AM PST

and they kept stacking them up and i kept knocking them down.

we were short staffed, like we are always short staffed. and there was no one to triage, so the charts kept piling up in a little row next to the desk where someone was supposed to be sitting but wasn't because we were short staffed (like we are always short staffed).

and the patients camped out in the rooms waiting for nurses who would never come because they hadn't gotten there yet because we were short staffed (because we are always short staffed) and it would be another half hour before i had a nurse (which no one bothered to mention)

and they were lined up down the hallway like they are always lined up down the hallway because they don't have anywhere else to go