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Archive for July, 2014

Tales From Bellevue Hospital: The Blue Chair

As I mentioned, I’m on call for our large semi-suburban hospital for the month of July. I was consulted for a patient who has monocular vision loss that is unexplainable, at least given the capabilities we have as ophthalmologists when we see patients at the bedside in the hospital. The consult brought back memories of Julys past as a resident on call.

Bellevue Hospital, and the Bellevue Hospital residents provide medical care for the New York City prisoners who are housed at Riker’s Island. This is actually quite an opportunity, especially for a child of suburbia like yours truly. It’s not as if I had never come across people in the criminal justice system prior to my Bellevue days, it’s just that I didn’t have such routine and regular contact.I don’t remember exactly, but there are at least three or four entire floors at Bellevue dedicated to the care of Riker’s Island inmates who have medical problems. One or two are for the criminally insane, and others who have some degree of mental illness. The remaining two floors house prisoners with problems as varied at coronary artery disease and pink eye. As disconcerting as it was for someone like me to enter a locked ward, the accommodations at Bellevue were at least a full order of magnitude nicer than those at Riker’s Island. This provided an interesting opportunity for Riker’s Island inmates to create a medical reason to leave The Rock, and created a very interesting learning opportunity for all of the residents  to discern real from not so real.

This  might have been the most fun part of my entire residency experience.

People who have something to gain from having an eye problem all seem to have the exact same complaint: “I can’t see.” Sometimes it’s “I can’t see out of my right (or left) eye,” and sometimes it’s simply “I can’t see.” The savvier the patient, the more subtle the symptom. The trick as the doctor on call is to simply demonstrate that their vision is substantially better than what they are describing. Oh yeah, it’s important to do so in such a way that you don’t make them too very angry; you don’t want to become a Bellevue Hospital “target” yourself!

Every resident develops a repertoire of tricks that he or she will use, a go–to list that tends to work for the majority of the malingering patients. To be truthful, especially when caring for children, sometimes the patient is actually convinced that he or she really CAN’T see. The kids are really pretty easy, though. I found, and frankly continue to find, that even with my limited attention span (often described as being slightly shorter than that of your average gnat) that I have more patience than almost any child under the age of 18. Most eye charts will start with a 20/10 line, and then move through 20/12, 20/15, and then several to many 20/20 lines. If you start at 20/10, by the time you get the 20/25 or 20/30 that line looks absolutely enormous! I think I’m batting about .997 in kids with 20/400 vision in the ER who “miraculously” and up with 20/25 vision in the exam room.

Folks who have something to gain from being diagnosed with visual loss weren’t always wards of the state or city. Occasionally there would be people who stood to gain from being diagnosed with profound visual loss for other, less existential reasons than wanting a ticket out of Riker’s Island. My favorite was a Hispanic woman who came with an entourage of family members, her complaint being complete and total loss of vision in both eyes from some vague and poorly defined trauma suffered at the hands of a landlord who was trying to evict the her from a rent–subsidized apartment. Her examination was totally unremarkable. Everything about her eyes was so  normal it was eerie. My suspicions were high because she just didn’t seem all that distraught over her new blindness, you know? There’s an instrument called an indirect ophthalmoscope which is used to examine the peripheral retina. The light we use can be cranked up to a level which is quite frankly rather painful. I explained to my patient through her translator that I was terribly sympathetic, and very concerned about how she would ever be able to survive if she was  evicted, what with her being totally blind and all. I just had this one last test to do, to look at her retina. With phasers set on stun I started to examine her eyes with the light cranked up. She started screaming in Spanish. What’s she saying? What’s she saying? Remember, now, this is a woman who has no light perception, everything in her world is black. Her son grabbed my arm and started yelling at me. “Turn that light off. It’s too bright. It’s hurting her eyes!” Yup, just another satisfied patient.

The prisoners really were the most fun, though. You had to be on your toes because some of them were actually quite dangerous. If the corrections officers were chatting amongst themselves in the waiting room you could be pretty sure that the patient in your exam chair was nonviolent. If, however, there was a corrections officer standing roughly 1/2 inch from each arm of the patient, well, that was one you had to worry about. But the prisoners got it, they got that this was a game. If they could beat me they got a stay at the Bellevue Hilton. On the other hand, if I got the best of them, it was back to Riker’s Island. The guys who complained of decreased vision in just one eye were actually not too difficult to fool. Again, all I had to do was prove that the vision and the supposedly “blind” I was normal. We quote discovered” all kinds of sight threatening needs for a new pair of glasses at two o’clock in the morning in the Bellevue consultation room.

The guys who complained of decreased or lost vision in both eyes were more challenging and therefore more fun. Can’t see anything at all? Piece of cake. All I have to do was prove that they had locked on to some image. There must be three dozen prisoners who complained of total loss of vision in both eyes who headed back to Riker’s Island one minute after entering my consultation room after they leaned over to pick up the $10 bill that I put on a footstool of the exam chair. Did you know that your pupils constrict when you focus on an image inside arm’s-length? You can imagine how handy that three-year-old Sports Illustrated bathing suit issue came in, and how many prisoners learned about accommodative pupillary construction after looking at THAT picture of Christie Brinkley.

There is one story out of all of my adventures with the Riker’s Island prisoners that stands apart. It was July, and I was doing my duty helping out the new first-year resident on one of his first nights on call. We got a call from the ER about this terrified patient who had lost vision in both of his eyes; he was defenseless. Dave, now a world famous pediatric ophthalmologist, was really unsure of how to proceed so I told him that we would do it together. We sat back and watched very carefully as the prisoner entered the room. He was totally on his own, not assisted in the least by the corrections officers. He managed to navigate around all of the little articles I had placed between the door and examination chair, not hitting a single one. He found the chair, turned just like you or I would, and sat down. His examination was perfect, naturally. After putting drops in his eyes to dilate his pupils this is what I said: “I can see that you are terribly frightened sir, and frankly I can’t blame you. I’m very concerned about your vision, and I’m going to do everything I possibly can to make sure that you are alright. I just put some drops into your eyes so that your pupils will dilate. Dr. Granet and I will then examine your retinas once the drops have worked. We are going to talk about what we’ve seen so far. Please go back into the hallway and take a seat in the blue chair, and we’ll come and get you in just a few minutes.” The prisoner left the room, once again navigating the “mine field” without incident.

Dave bowed his head, a little tiny twitch at the corner of his mouth as he shook his head. “There’s only one blue chair out there, isn’t there?” He smiled as he strolled over to the door. Sure enough, there was our patient, very calmly sitting in the single blue chair, surrounded by a dozen empty red ones!

We had to invite the corrections officers into the exam room when we explained our findings.

Sunday musings 7/20/14: The Risk of Unshakeable Belief

Sunday musings…

1) Fonzie. Henry Winkler is 68 years old. Ayyyyy…

2) Open. Oldest golf tournament in the world coming to a close as I type. Sergio comes up jusssst a bit short. Again.

Dude’ consistent. Gotta give him that.

3) Aviary. Mrs. bingo is the “Bird Whisperer.” Who knew there were so many types of birds in suburbia?

I remember when a robin was an exotic creature.

4) Change. The only thing that is constant is change. This applies everywhere to everything. Next weekend will bring the latest edition of the CrossFit Games. There will be change. Count on it. I have absolutely no inside information whatsoever, but you can make bank on this. There will be change.

How could I possibly know this? Well, a part of it is just a basic fact of life. Stuff changes. The other part is simply history. If you’ve been paying the least bit of attention the last, oh, 10 years or so, you’ve notice that the folks who run things in our little CrossFit world are ever and always changing things up. I’m not really sure if the Black Box is outwardly (or inwardly) any different, but the leadership team is constantly changing up the left side input to see what comes out of the right side. From where I sit each change has brought a net improvement. The only thing we know for sure is that there will be change next week at The CrossFit Games.

Now in reality, unless you make your living from The Games of from CrossFit, this particular change is more interesting than integral in your life. It’s the fact of change, the constancy of change, and more so how you handle it both tactically and emotionally, that determines your destiny. Prepare for change and plan for change, because change is what you’re gonna get.

5) Unshakeable. This week I spent some time talking to a couple of folks who, unbeknownst to them, were talking about each other. Well, talking to them is not really accurate–they were having a discussion and I was having a listen. Both were talking about the effects of a particular happening on a particular person, effects that both could surely see if only they cared to remove their blinders and look. They told wildly different stories. Their belief sets were so unshakeable, so impervious to penetration by petty inconveniences like facts and reality, it was as if they wore not lenses to clarify but masks to obscure.

The blind running from the blind, if you will.

I’m fascinated when I see this, and I do see this almost every day when I am plying my trade. So much of what is “known” about medicine isn’t really known at all but “felt”. I constantly run up against an unshakeable belief that is often expressed in a statement that begins “well, I would think that [you] would…” Indeed, I heard this from both folks telling me what was transpiring. I’m fascinated and exasperated in equal parts when I am on the listening end of this equation because of how completely this unshakeable belief nullifies the otherwise logical power of observable, measurable fact.

If I step back and think a little more deeply about this phenomenon I am also terrified that I, too, may harbor similarly unshakeable beliefs that blind me to the truths of a fact-based reality. This weekend brought a gathering of true experts in a particular field of my day job, one I was quite flattered to attend. There were a couple of points that I’m just convinced my colleagues got wrong, points of view it looks like I shared only with myself. Am I right? Is my insight so keen, my ability to analyze the data presented so much better, my advice so advanced that I am just a full step ahead of the rest of the group? Or is it rather that I am clinging to a point of view supported only by the virtual facts created by beliefs I am unable or unwilling to walk away from? The simple awareness that this may, indeed, be the case does place me in a better position than either of my conversational partners as far as ultimately being right, but is that enough?

Blinders of not, I guess we’ll see, eh?

I’ll see you next week…

Posted by bingo at July 20, 2014 11:06 AM

Tales from Bellevue Hospital: On Call 4th of July

I am on call this month for the largest community hospital on the West Side of Cleveland. Covering a semi-suburban ER is quite different from covering a true big city ER, especially when the semi-suburban hospital has gutted both its trauma and eye services. My on-call role now is little more than that of foot servant, covering the loose ends of other people’s arses in the pursuit of a perfect chart. Bellevue, at least the Bellevue I knew in the 80′s, was quite a different story. Although it was July it was July in New York, pre-Guliani New York, and it was Bellevue Hospital.

There are only two kinds of people in New York City: Targets, and people who hit Targets. At Bellevue we took care of the Targets.

It’s the first weekend in July. For most people in America that means the 4th of July and everything that goes along with that. Barbecues. Fireworks. Festivals and ballgames of all sorts. And beer. Lots and lots of beer. But in that curious sub-culture of medical education the first weekend in July means the first time on call for newly minted interns, newly promoted residents and fellows of all sorts. Everyone and everything is new, just in time for July 4th and its aftermath.

Funny, but I ended up on call for every 4th of July in my four years of post-med school training. I’m not sure which, or how many, of the residency gods I offended, but whatever I did I apparently did in spades ’cause I hit the first weekend jackpot every year. I have no memory of my first on call as an intern, but the “Target Range” was open for business those first couple of years at Bellevue, for sure! In fact, if memory serves, the phrase “Target” was coined by yours truly that very first weekend of that very first year as an ophthalmology resident.

“Hey Eye Guy! We got a John Q. Nobody who got shot in the temple just standing on the subway platform. Says he can’t see. Whaddaya want us to do with him? By the way…welcome to Bellevue.”

Crowds and beer and heat and stuff that explodes. Welcome to Bellevue, indeed. Some poor schlub survives the bar scene after the parade, makes it through pickpocket alley intact, gingerly stepping over detritus living and otherwise, only to get shot in the head as the A Train approached the station in a random act of anonymous violence. The bullet entered through the right temple, destroyed the right eye, and wreaked havoc in the left eye socket before coming to rest against the left temple. Right eye gone and malignant glaucoma in the only remaining left eye. And there I was, all of 3 days into my opthalmology residency, backed up by a chief resident of similar vintage. Whoa…

There’s no way to avoid it. After all, med students have to graduate and residencies have to start some time. There’s just this unholy confluence of weak links in the system all coming together in time for the second (after New Year’s Eve) most difficult ER day in our big, academic hospitals. Get sick or injured on June 4th? Everyone’s on top of their game and everyone’s in town. July 4th? The fix is in, and the game is as rigged against you as any carnival game attended by a dentally challenged carnie.

As I sit here, an Attending on call for yet another 4th of July weekend, covering the ER and cowering each time the phone rings, the Tweets and Facebook posts heralding the arrival of a new crop of interns and residents send me back to Bellevue. Year 2, cursed again, covering the spanking new 1st year ophthalmology resident (was it Dave?) as he got his welcome “gift” from the ER. “Hey Eye Guy. We got a Target down here for ya. 10 year old girl. Some dumbass tossed a lit M80 to her and she caught it. Went off before she could get rid of it;  blew off her right hand and looks like her right eye is gone. You from NY? No? Welcome to Bellevue, pal.” Yup…there’s something about the 4th of July in every teaching hospital in the U.S., and just like everything else, whatever it is, there was more of it at Bellevue.

Only two kinds of people in New York, Targets and people who hit Targets. At Bellevue we took care of the Targets.

 

Sunday musings 7/13/14

1) Newbie. “Lovely Daughter” just joined a CrossFit Box! The entirety of Clan bingo now does CrossFit. Every night Mrs. bingo gets a call from “Lovely Daughter” with a report of her WOD, as excited as any and every CrossFit newbie for ever and ever. Mom and Dad are thrilled for you, Megan.

Welcome aboard. Fasten your seatbelt.

2) Somebody. “Aren’t you somebody?” Or even better/worse: “Weren’t you somebody?” In a see and be seen society these  questions are asked with great regularity. The asking and the answering are equally amusing.

Both questions are really rather bold and intrusive, don’t you think? What does it even mean to be a someone, anyway? If you ARE a someone what’s it like when somebody sees that you are someone but can’t figure out just who? I can’t imagine anything good about someone remembering that you were once upon a time a someone and aren’t any more.

For whatever it’s worth, I am a C-list someone who can only aspire to becoming a B-list overnight sensation. My anonymity is assured in perpetuity.

3) Goodwill. The memory of good deeds performed or kindnesses extended can be called goodwill. The granting of favors is sometimes called “extending goodwill”, an act that builds up a reservoir of the same. Extending goodwill with no apparent benefit to yourself is kind of like collecting triple value coupons. One who has accumulated goodwill over time can withdraw from that reservoir in times of need.

How long do you think goodwill lasts? Is it a forever thing or is there an expiration date? If it doesn’t last forever is it the kind of thing that just leaks out, kinda like a helium balloon left over from a big party, descending slowly back to earth and then collapsing upon itself? Or maybe it lasts and lasts and lasts, and then POOF, gone. I also wonder if there is a geographic component to the durability and duration of goodwill. You know, kinda like a WiFi signal, 3G or 4G on your cell phone. If you were once in a position to extend some goodwill and there is now some distance between you and whoever, is there still goodwill there upon which you can call? Or does it fade away like an echo left far behind?

Every now and then I think about this a bit. Not because I’m all that concerned that I might need to call in a goodwill chit some day, or that somehow I might not get some kind of payback or owezee. No, it’s more about being remembered, I think. Not the goodwill so much. Me. I guess when I wonder about goodwill, whether it lasts, if it weathers both distance and time, I’m thinking of whether any goodwill I might have built up is enough for people to remember me.

Am I still someone, or did I just used to be someone.

I’ll see you next week…

Smartphones Have a Virtual Dialtone

There are a couple of broad-brush themes I find myself drawn to, things I find myself visiting with some regularity. Communication is one of them, and this week the specific thing that came up several times was how you might choose to communicate with a particular person or group of people. There’s always a trigger for these ruminations, this time the jarring interruption of an examination in my office by a ring tone that my patient surely thought was quite clever and altogether appropriate for any and all occasions. Yeah. No. Especially not while sitting in the exam chair in front of a doc who pointedly does NOT carry his cell phone while on the job.

We all got to talking about what cell phones have become and how we use them. A bit later in the day a patient was lamenting the presumed need to carry a smartphone with all of the attendant capabilities and inferred responsibilities and demands. You know the drill: each text is mission critical and cannot be ignored. An answer must be on its way before the backlight on your phone dims. You no longer have the answer to any question literally at the tip of you fingers, you now have the obligation to GET that answer, right now, lest you end up with questions in a queue. Questions have rights, too, in the age of the smartphone.

It’s insidious and seemingly irresistible, even for a guy who hangs his cell phone on a peg in the office (like a gunslinger entering an old West saloon). The “gotta answer” text now more compelling than a phone call ever was before because you can answer that text so quickly, almost…ALMOST…without interrupting whatever you may be doing otherwise. Unlike a phone call, where you must break away both attention and voice in order to communicate with someone who is not right there with you. Texters are now to the point where you need to text and ask if it’s OK to call. I must admit that even though I am nothing short of terrible at the physical act of texting (my auto-correct is in therapy with self-esteem issues) I, too, have been seduced by the ease with which a thought/need can be sent off RIGHT NOW, saving me the angst that would occur if I somehow forgot to transmit that thought/need if I had to remember it for a later transmission. I found myself becoming annoyed that my Mom doesn’t text (or email, but that’s a whole ‘nuther thing) because if she did I would never, ever forget those mission critical things I was supposed to remember and report.

But then, of course, it hits me: some people are always worth the effort of a phone call, even if they DO text (or email). In the natural evolution of communication a phone call–a real, live, use your voice and your ears phone call–has become as significant a gesture as hand writing a letter once was. Some things you just have to say out loud, and some people you just have to call up and talk to. You don’t text your grandmother to tell her about your first big boy/girl job after college. Your grandmother is worth a call even if you’re just telling her you remembered to pick up orange juice. Your Mom and Dad, POSSLQ, doctor, the guy who’s fixing your toilet–if these people want or need a call, a call is what they should get. Some communication is nothing more or less than a transactional transfer of information, while other communication is much more personal. Truly effective communication occurs when both sides are in agreement about what type of communication is occurring. Every communication with my Mom, for example, is personal, and would be even if she had and used a Galaxy whatever. As a matter of fact, even a phone call with my Mom is a kind of compromise as far as she is concerned because I am not able to just drop by to catch her up on whatever it was that she tasked me with reporting. Indeed, face to face communicating trumps even the handwritten note for immediacy, engagement, commitment, and conspicuous effort.

Eye exams are face to face. I was able to  communicate with my patient just how I felt about that phone going off in my exam room with one eyebrow tied behind my back.

 

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