Wednesday, February 20, 2013

Let's talk about how not to be an asshole to your patients.

Or, for that matter, to your family members when they're in the hospital.

(Inspired by this post at XOJane, and by my own experience over the weekend.)

I had a patient this past weekend who was, by any definition, a Big Girl. Several inches over six feet, broad and strong in proportion to her height, and well over 300 pounds. She'd had a crazy-ass, rare clot in a weird place that had landed her with us. She also had a relative who, while well-meaning, was a royal pain in the patookus in regards to her weight. The relative, incidentally, was also tall, but very, very slender. And had an obsession: her relative's--my patient's--weight.

So I'm in the room, talking to the patient about her Cray-Cray Clot, and the relative starts in about the patient's weight. "You need to tell her she's fat," the woman says, "and that she needs to lose weight."

This is true. She is fat. She's way the hell over what any rational person would consider a healthy weight.

Nonetheless, she had recently finished a half-marathon. She played tennis twice or three times a week, and led a water-aerobics class a couple times a week. Her mobility was not impaired. Her lipids and blood pressure were normal. Medically speaking, she had no problems at all save an extra hundred pounds.

So I turned to the patient. "Do you own a mirror?" I asked. "Yes" was the reply. "Do you know that you're fat?" I asked. "Yes, of course" said the patient. "Are you aware of research that finds that extra weight can lead to health problems?" "Yes."

"There. Done" I told her relative.

Which brings me to my first rule of dealing with fat people: Do not treat them as though they don't know they're fat. 

As a fat person myself, I am constantly reminded that I'm fat. I can't buy clothes from straight-size stores, I am always the largest person in any group picture, and there are some things I find uncomfortable to do because of my weight, like going down stairs. (Going up stairs is easier on the knees, and my aerobic capacity means I'm often outdistancing my skinny colleagues. Still. . .)

If you're fat, you know it. Please give us fat folk the benefit of the assumption that we have brains.

Then the relative asked me straight out if the Cray-Cray Clot was due to the patient's weight.

It wasn't, and I told her so. It was due to the fact that the patient has a rare clotting disorder that hardly ever shows up in women.

In asking that question, Relative had fallen into the same trap that all the doctors who'd seen Patient had fallen into for months. Despite an unyielding headache and neurological changes, the docs who'd seen her hadn't looked at her brain; instead, they'd blamed her weight for her symptoms. Doing so had led to a three-month delay in diagnosis, incalculable damage to her brain and spine, and a lot of pain.

This is Rule Two: Not everything that is wrong is due to excess weight. Do not be blind to the fact that there might actually be a problem that can't be expressed in BMI.

Back in the day, doctors blamed wandering uteri for everydamnthing that went wrong with their female patients. This is exactly the same thing: blaming the most obvious factor for all the trouble ever. Fat equals wandering uterus in today's medicine. Do not blame fat: look for an underlying cause. Examine your patient's general health and activity level. Dig deeper.

Eventually, Family Member took me aside and asked me to have a serious talk with the patient about her weight. If she would just eat less, Family Member said, all her problems would be solved.

I leave it as an exercise for the reader to determine whether or not this is true. (Hint: it's not.)

By the time you get to be fifty, or a hundred, or five hundred pounds overweight, there are other things going on besides overeating. It's not a failure of willpower or a lack of knowledge and understanding. Thirty years ago, we had that attitude about drug abuse: if the person would Just Say No, things would be unicorns and rainbows and the world a better place.

Really severe obesity is a product of a multitude of factors, most of which have nothing to do with food per se. Therefore, my addressing one facet of the problem by saying "Hey, I just met you, and this is crazy, but you eat like a fucking pig, so cut back, maybe" is not going to help. At best, it's telling somebody something they already know. At worst, and most commonly, it demonstrates a lack of respect for whatever deeper issues that person's dealing or not-dealing with.

Morbid obesity is like heroin addiction: it starts from a place deep in somebody's psyche and has to be addressed holistically.

So here's Rule Three: Fat is not about food. Fat is about something else. Don't insult your patient, or your loved one, by assuming that it's just about the calories.

"If you want to help," I told Family Member, "you could reassure Patient that you love her no matter what her size is, and that you'll be there for her if she needs you. Right now, you're telling her that your love and acceptance is conditional on her being thinner. That's a losing game."

Finally, and without illustrative examples, here is Rule Four:

Fat is a descriptor, just as "strong" or "red-haired" or "really good at eye makeup" is. "Fat" does not mean "lazy" or "slovenly" or "smelly" or "bad."

Fat is just another adjective. Avoid making value judgements about somebody just because they're bigger than you, or--equally important--hating yourself because you're not at an ideal weight.

If I had my way, everybody would feel comfortable being who they are. Nobody would feel bad about how they look or however it is that they don't conform to whichever ideal is in fashion. People would eat greens and trot around enthusiastically and take their baby aspirin daily and be cheerful about their futures.

That's not likely to happen soon, so in the meantime I'll deal with the fracas surrounding fatness.

Saturday, February 09, 2013

Loud Cheers! (For several reasons. . .)

Doctor Annoyance is going away. I don't care where or when, though I know when the when will be, and believe me, it's not soon enough: he's going away.

Doctor A has been a thorn in my side now for longer than I care to consider. He's one of those doctors--you know, the ones who can't find a phone number on their own, or who ask you stupid, unimportant questions in the middle of a crisis, or who think they're being cute when what they're really being is totally off the chain and for God's sake will you just TAKE IT DOWN A NOTCH ohmygawd how many times do I have to tell you

. . . .Anyhow, he's going.

And, with him, goes another colleague--one so toxic (as the kids say) that I didn't know how much my work life was being affected.

I wrote a piece t'other day for Scrubs about toxic workplaces and nasty, poisonous coworkers. I hadn't connected that bit of writing with anything that was going on in my own precious unit until now. Turns out I was speaking more truth than I had ever imagined.

For the last two years, my daily life's been made more unpleasant by somebody who can't see the good in anything. Swear to Frog, if this person won the lottery, patented a device to reverse global warming and remove pollution from the air, and cured cancer, all in one afternoon, there would still be bitching happening. Some people are never happy, and this is one of those folks.

And they're leaving. Cue my happy-dance. They're leaving, and they're taking Doctor Annoying with 'em, and for the next week, I am going to be blissed out and just smiling like a fool.

In other Hooray news, I have a confession to make: a sexist, horrible, awful confession:

There is some serious eye-candy happening in my unit these days.

We got a new crop of residents in as part of the half-year switcheroo, and although I know most of them, there are a few lovely strangers to gaze upon. (Yes, yes, I know. They're all young enough to be my children and they're professionals and so on and so forth, but dayum.) HR has also given the go-ahead to hiring what seems to be America's/Australia's/Canada's/Backobeyondistan's Top Model candidates for the night shifts, and all of 'em are orienting, in succession, to the NCCU.

Aside from a I-will-always-say-something-stupid moment when I tried to guess where one of the newbies was from (I guessed Ireland; turns out the correct answer was New Zealand), things have been going swimmingly. Not only are these guys--because they're all male, and what's up with that?--easy on the eyes, they all came in knowing what three-percent saline is for and how to do an NIH stroke scale exam. They're all experienced. They're all certified. All I've had to do the last three weeks is show 'em where the coffee machine is, tell 'em how to access the computers, and turn 'em loose. This is in contrast with what I've been doing lately, which involves equal parts babysitting, computer training, and hand-holding.

Is there an asteroid due to hit soon?

Because, if there is, I want to open my mouth as wide as possible and show it my tonsils before I get blown to cinders. And therein lies the last Hooray bit of news: my two-and-some year's checkup was clean as a whistle.

Dr. Crane said that thing that used to be my mouth looked "beautiful," and as I was getting all puffed up about it, added, "The Prosthetic Elf always does such good work." Still, it's nice to know that I am still officially without evidence of disease. The next exam's in August, and I'll have a good old time freaking out about that, as I'm supposed to get an MRI a week prior.

I'm tempted to deck out an IV pole with streamers and fake flowers and ride it around the unit, waving like Queen Bess at everyone.

Monday, February 04, 2013

Seems my job definition just expanded.

The screaming was so loud that it brought me out of the room nearest the nurses' station with a "What the HELL?"

It was a toddler. I don't know jack about babies, except that they're generally wet at one end and loud at the other. This one was both. This one was open-mouthed, red-faced, screaming its little head off, in the arms of my flummoxed-looking coworker. He (the toddler, not my coworker) seemed to be about walking age, maybe a little younger; a cute kid, aside from that awful noise.

So we took him into one of the larger storage rooms and proceeded to play games like "What's on my head?" and "Can we shut you up with cookies?" Coworker dealt with the diaper while I went back to being a nurse.

After thirty minutes of nonstop hollering (poor kid was really upset), the child's father came back to get him. The child's father is an attending physician--not on the neurocritical care service, thank God--and had come in for morning rounds. His wife was out of town. Apparently babysitters do not exist.

Except in the neurocritical care unit! This is the fourth time in as many weeks that a male, attending physician has brought one or more children with him and left said child(ren) in our care for anything up to an hour. One dude dumped his kids off in the nurses' station break room around lunchtime with hasty instructions to "feed them something and keep them entertained."

I can't even. There are so many things to unpack here that have to take them in list form:

1. It's flu season. Children are, it's generally recognized, moving receptacles of bugs.

2. Hospitals are notoriously dirty places. Kids put everything in their mouths. Bad combination.

3. Nurses are not babysitters. We have things to do, even on weekends.

4. Bitches do not, universally, love babies.

5. Can you imagine what would happen if a resident brought in his or her kids?

6. Oh, God, if a female resident or attending brought in her kids, she'd never live it down.

7. Kids are noisy. It's part of being a kid. Units where stimulation is kept to a minimum is not a place where kids can or should be noisy.

8. You are old and experienced enough to know better.

9. WHAT THE HELL ARE YOU DOING, BRINGING YOUR KID TO ROUNDS? It's not like rounds are a sudden, unforseen emergency. They happen every day at a given time. You have time to prepare, to have a plan A and a plan B and even a plan C, should that be necessary.

Thankfully, the charge nurse of the other CCU that shares our floor said something to the doc. Had I opened my mouth, I would've blasted him to a cinder and salted the charcoal. Still, we wrote him up--the only concrete action we can take when a physician does something so inappropriate.

If this were just one physician, or just one service, it'd be easier to handle. Instead, it's different guys at different times, which means it's a part of the hospital culture. That'll be fun to address.

So, guys, if you're thinking that it's a slow Saturday at Sunnydale General, and that nobody'll mind watching your child for however long you need 'em to, just don't.

Just. Don't.