Residential Space A creative outlet during residency, turned ongoing virtual soap box

What I have learned from the Harborview ER  1

Posted on March 28th, 2006. About Health Care, Ramblings.

The city of Seattle is in shock over what is now being called “The Capitol Hill Massacre.” In a city where acceptance and tolerance are a given, Capitol Hill is the neighborhood reflective of Seattle’s welcoming attitudes. Rainbow flags fly from many businesses, people talk openly on the streets while waiting for buses, and the area’s high street features everything from Indian cuisine to handmade fabrics. It is generally considered one of the more desirable places to live. The thought of seven people dying violent, tragic deaths in a home there recently is a bit surprising, to say the least.

Just prior to the shootings, I finished my overnight shift in the Harborview Medical Center emergency department. When I returned later in the evening for another shift, the residents and attendings who had been on during the day looked emotionally and physically drained. The surgery residents seemed unable to comprehend that they were resuscitating these trauma victims featured in the national news media. As has been reported publicly, another victim died after reaching Harborview, and two others made it to the intensive care unit. During the night, I saw a stabbing victim, several young people in a horrible motor vehicle collision (one died), multiple injuries from fist fights, “car vs tree,” “pipe vs head,” cardiac arrest, and of course countless overdoses and intoxications brought in by the police. Everyone left feeling depressed and tired.

This past month has been a frustrating one. I have “treated” some of the same intoxicated individuals on five or six different occasions within a four week period. I have been sworn at, had to order restraints on meth overdoses for taking swings at paramedics, and seen people who come to the ER at 4AM for indigestion they have had for the past two weeks.

Over the past two nights, though, things have come together for me. I have really learned to care for these patients. For example, intoxicated patients get an IV and a good dose of thiamine (a vitamin those with chronic alcoholism are often lacking from malnutrition). Then, they get IV fluids as they sleep for a few hours. Eventually, from all of the fluid, they have to go to the bathroom. When I see a patient walking to the restroom, I know he/she is stable enough to walk safely out of the hospital. When they go back to sleep, A) I take his/her blanket away. He/she gets crabby, but some can still sleep. If this is the case, then, B) elevate the head of the bed to a 90 degree angle and withdraw the pillow. This may help someone wake up, or make him/her even crabbier. C) Speak in a kind, but firm tone about how it is going to be a lovely day in Seattle and you would hate for them to miss out on it by lying on a gurney in the ER. If all of this has still been ineffective, D) swing his/her legs over the side of the bed and get him/her on his/her feet. No one who has walked to the bathroom will fall from this; everyone wakes up. Ninety percent of these patients (once awake) are very pleasant, thank me for the care they have gotten, and leave willingly.

This is not the medicine that I learned as a medical student, but knowing people’s behaviors and understanding how to negotiate realistically was a crucial part of surviving this past month. Knowing how homeless shelters and detox programs operate was also very important. I also got to run my first ACLS (Advanced Care Life Support) code and experienced what it is like to give orders to a room full of providers during a cardiac arrest. I placed numerous central IVs into jugular and femoral veins, performed lumbar punctures for spinal fluid sampling, and learned how to throw a quick IV into superficial neck veins. Looking back, while the experience was stressful and exhausting, I feel like twice the physician I was a month ago.

What can I say? There is bad stuff out there. But I finish my ER experience hoping I am better able to deal with it.

Achieving Yuppiedom  4

Posted on March 24th, 2006. About Ramblings.

Yesterday, it was brought to my attention that Evan and I are yuppies. A little context: at the end of August Evan and I had our first party in our new condo. A good friend of ours had a friend in from out-of-town that weekend, so she brought him to our party. They stayed for a bit, talked to some people, and then left early for their high school class reunion. Well, yesterday it came up that her friend didn’t care for our party because there were “just a bunch of yuppies” there.

My first reaction was, of course we’re yuppies. Then I realized he had meant this in a negative way. I recountered this to Evan, and he agreed that we are yuppies, explaining that the term stands for “young urban professionals.” When I searched for the term on Wikipedia this morning, I found that he was correct – it is explained here. I will include an excerpt here:

“Yuppie, short for “Young Urban Professional,” describes a demographic of people comprising baby boomers as well as people in their late twenties and early thirties. Yuppies tend to hold jobs in the professional sector, with incomes that place them in the upper-middle economic class. The term “Yuppie” emerged in the early 1980s as an ironic echo of the earlier “hippies” and “yippies” who had rejected the materialistically oriented values of the business community. Although the original yuppies were “young,” the term now applies as well to people of middle age.”

The article goes on to describe the Yuppie stereotype, people who are materialistic and selfish. They drive cars like BMWs and SUVs, and they spend a lot of money on gaudy items to show off their wealth. I find this very amusing, not just because I still drive my 1998 Saturn SL that I have driven since my freshman year in college, but because the only thing we have really ever spent money on is our condo in order to enjoy a view of Seattle’s skyline; skylines have always brought me great joy, but I don’t think I will ever be able to purchase one.

But rather than growing defensive over a judgmental term, I’ll break the comment down this way. I am 27 years old (young), live in Seattle (urban), and have been a practicing physician for nearly a year (professional). In the truest sense of the word, am I a Yuppie? Hell yeah! 🙂

My beef with Express Scripts – Part 2  8

Posted on March 22nd, 2006. About Health Care, Ramblings.

My handful of readers may recall my recent post in which I expressed my frustration over being unable to obtain my birth control pills through my insurance company’s preferred mail-order pharmacy, Express Scripts. To summarize, I sent them a prescription from my doctor for ortho tricyclen, they chose to fill it with a generic (tri previfem), they are now out of tri previfem, and were stating that they could not fill it now with ortho tricyclen, the original medication indicated in the prescription. The *only solution*, they claimed, was for my doctor to write another prescription, and I could mail it to them. They insisted that once a prescription has been filled, even with a generic of a different name, only that generic can be dispensed.

Okay, so I went to my neighborhood Walgreen’s today, and they confirmed that tri previfem was unavailable. Fine – I will accept that this generic is unavailable for the time being. BUT the first question the pharmacist had for me was – would it be okay to provide me another generic or ortho tricyclen? Ummm, YES, I told her. She warned me that my insurance may not cover it, to which I replied that I didn’t care at this point. So I questioned her – Are you SURE you can fill a prescription with a different generic once it has already been filled with a generic of a different name? Of course, she answered, we do it all of the time. Otherwise when generics are discontinued patients would have to return to their doctors for prescriptions too frequently. EXACTLY. Thank you. I feel vindicated – somebody gets why this was bothering me. Do you ever have those moments when something seems perfectly reasonable or unreasonable to you, but those around you are not bothered by it? And you think – is there something wrong with my brain? Why am I not getting this? Now I feel justified – there is something wrong with the representative and “supervisor” at Express Scripts.

Who knows – perhaps I will go to retrieve my prescription tomorrow and the pharmacist will say – Sorry, I’m a new graduate fresh out of pharmacy school and I didn’t know that I wasn’t supposed to be filling prescriptions this way. Oops. But I will assume for the time being that she knows what she is talking about moreso than a customer sales representative without any medical training.

My beef with Andrx Pharmaceuticals, Express-Scripts, and “The System”  3

Posted on March 17th, 2006. About Health Care, Ramblings.

Wow, I am fuming mad about another experience. I can only imagine how James would react to something like this were he in my shoes. This is a big one.

So it’s one of those things about being female – taking a little pill each night that A) prevents babies before one is ready for them, B) regulates the cycle thus preventing anemia, and C) keeps the hormones in balance to prevent acne and other un-pleasantries.

Here’s a little background on this situation to better explain why I am so freakin’ mad. Since I began working in June 2005, my new insurance company, Uniform Medical, will only partially reimburse for prescription drugs that are filled through their preferred online/mail-order pharmacy, Express Scripts. In June, I had a great amount of difficulty getting my prescription transferred from my previous insurance company’s mail-order pharmacy to Express Scripts, and then rather than sending me a letter or calling and refusing to fill the order, Express Scripts just didn’t fill it. When I contacted the company, wanting to know where my pills were, they gave me this, “Oh yeah, the nurse practitioner never wrote a DEA number and we can’t fill it without one.” First of all, that is BOLOGNA/BOLONEY – DEA numbers come into play with controlled substances. I never write my DEA number on prescriptions for my patients because I don’t want the wrong person getting ahold of it and forging scripts for their street associates with it – and it has not been a problem. My hospital’s pharmacy encourages residents not to put our DEA numbers on there in order to protect them – if they need it, they call me and I provide it to the pharmacist over the phone. Second of all, Express Scripts never attempted to contact the nurse practitioner who wrote the prescription (whose number was on the script) to ask for the DEA number, and third, they never attempted to let me know that it was not being filled.

Anyway, eventually (let’s call her my “primary care provider”) wrote me a prescription for a year’s supply of birth control pills – Ortho Tricyclen, a popular brand, now available in several generic forms. Physicians can either sign on the line that says “Substitution Permitted” or on the line that says “Fill as Written.” My primary care provider signed on the “Substitution Permitted” line, as I almost always do as well, so that the pharmacy and patient have flexibility should the trade brand cost too much or if the trade brand is unavailable. I sent the script to Express Scripts and received the medication within about two weeks. Instead of sending Ortho Tricyclen (the trade brand), they sent Tri-Previfem, a generic form manufactured by Andrx Pharmaceuticals. Fine. Problem solved. FYI – these pharmacies often send patients a three months’ supply of meds, and expect one to request a refill a few weeks before running out.

Today, I thought – well, I have two weeks left before my pills are gone. Time to reorder. I attempted to reorder on the Express Scripts website, but when I typed in the Rx number, nothing was coming up. So I called the toll-free number, spoke with a phone representative, and she explained that Tri-Previfem was on back order, and that it would be the end of April (at the earliest) that Andrx Pharmaceuticals would be able to provide Express Scripts with an adequate supply of this medication. Fine. So I explained that I would accept any other generic form that could be substituted for Ortho Tricyclen. I’m sorry, said the helpful representative, but your doctor will have to write another prescription and I will have to mail or fax it to Express Scripts. What?! I told her that my doctor had already written a prescription for Ortho Tricyclen, and that it was Express Scripts who filled it with this now-unavailable generic. They told me that (apparently this is a problem with “The System”) once a prescription is filled with ANY MED – be it the trade drug or a generic form – the prescription is only good for that single medication, and nothing else can be substituted later. So even though my prescription was written for Ortho Tricyclen, and Express Scripts and Uniform Medical decided to fill it for Tri-Previfem instead, now the prescription is only good for Tri-Previfem and there is no way to fill it for what the doctor actually prescribed in the first place. I asked the supervisor with whom I eventually spoke why Express Scripts filled my Ortho Tricyclen prescription with a generic form that they could not guarantee I would be able to receive on refill three months later, to which he replied, “Well, you could have a local retail pharmacy call us, and we will be happy to give them the prescription information over the phone.” My response was incredulous: “But you just said the problem was that the drug company cannot provide the medication because the drug is on back-order. That means no one should have it. And if my local pharmacy does have it, not only will I have to pay full price for it because my insurance company demands that I go through you guys, but it also means that the drug is available and that you should have it.”

I swear, this is a totally broken system. What if this was a drug to keep my blood pressure from getting outrageously high, or a blood-thinning medication to keep that second pulmonary embolism from occurring? I hate being forced to use a preferred mail-order pharmacy that provides crappy service, but not easily being able to go elsewhere if I am dissatisfied. I suppose I could always pay full-price at the local pharmacy, but as we all know – medications are expensive, and this is not always feasible. I am so angry that I want to yell at someone, but I don’t know who should face my wrath. The Express Scripts guy eventually agreed to give me a credit on my account with them for the difference between what I will end up paying at the retail pharmacy and what I would have paid with them, so I guess that is a small victory. I think I will next call Andrx Pharmaceuticals to jump on them for over-committing their drug (if this actually turns out to be the case). Then, I am going to figure out why in the hell a prescription cannot be filled for its originally prescribed drug after it has been filled with a generic. That is just plain dumb. If I find this is a federal law, then I might have to go on a Shawshank Redemption letter-writing campaign – you know, where Andy DuFresne wrote a letter a week asking for funds for the prison library until the powers-that-be got sick of him and gave him what he wanted. And if that doesn’t work, well – I’ll probably be a mother by that time.


Thoughts on Personal Finance  0

Posted on March 11th, 2006. About Money.

My sister-in-law, Martha, recently constructed a blog post, explaining her views on personal finance, not over-spending, and expounding on how at times she feels she is one of the only young adults concerned with money, investing, saving, etc. Then, in a subsequent post, she recounted several expensive purchases she had made recently and humorously wrote something along the lines of “so much for being financially responsible.” 🙂

I appreciated this post, because it is a concept to which I can totally relate. As many of you know, I am regularly posting diatribes about personal finance and money, and ranting about how people my age are clueless about money. I recently completely paid off my American Express card’s balance, the only credit card on which I owed a cent (the HELOC on my home doesn’t count, methinks). Swelling with pride over this victory, and beaming at my lack of credit card debt, suddenly I was faced with standing in a wedding. This required a plane ticket to South Carolina, a hotel room, a bridesmaid’s dress – and before I knew it, American Express and I were once again well-acquainted. Back into the desk drawer it goes until the balance is gone.

On a brighter note, yesterday was payday, and the 403(b) increased again. In addition to this and my Roth IRA, I also opened a taxable investment account with Fidelity a few months ago. I just can’t seem to get enough.

Jon Stewart Hosts The Oscars  1

Posted on March 6th, 2006. About Entertainment.

Evan and I enjoyed watching Jon Stewart host the 78th Annual Academy Awards this year. His jokes were witty, classy, and at times – downright hilarious in that dripping-with-irony characteristic to The Daily Show. That being said, it was *very* obvious that his proximal audience did not find him as amusing as we (and from the reviews I have read this morning, most of America) did. It boils down to the fact that many Hollywood figures, whether consciously or subconsciously, believe themselves to be members of an elite class, and it was painful evident that they are unable to laugh at themselves. They failed to realize they were being delivered first-class entertainment and often appeared unenthused when Stewart would deliver a well-crafted joke about wealth/class or Hollywood stereotypes or Scientology. They also failed to understand that Jon Stewart has been more effective in bringing a huge audience to the side of their causes than most of them combined. If they are dissatisfied with President Bush and the war in Iraq, then they should be kissing Jon Stewart’s feet. In any case, I think MSNBC’s article (thank you for this one Evan) describes the evening very well – click here to read it.

Now for bragging rights – I correctly chose 17 of the 24 winners this year in the various categories. Some of them I had not seen (short action live film, etc) but correctly guessed merely based on the titles, which got me to thinking – if people vote for politicians without researching the candidates, are they possibly voting on Academy Awards without actually seeing the films? The one major category I missed was Best Supporting Actor – I knew George Clooney had won the Golden Globe for Syriana, but I was impressed enough with Matt Dillon’s performance in Crash to go out on a limb and place my vote behind him. While I thought Munich was a better film than Brokeback Mountain (although Brokeback was excellent), initially I thought the “Best Picture” award would go to Brokeback because of the publicity it had received. That is, until I saw Crash last week, and I knew it had to win this coveted category. It was, by far, the best movie of the year, and there have been a lot of good ones. The storyline, intricacies of plot, editing, acting – all flawless. It was the perfect movie.

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