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Fish, Fish Oils and Cardiovascular Disease

Years ago the scientific researcher responsible for the promotion of fish oils as an antioxidant and protector against vascular disease recommended we all eat two fleshy fish meals of cold water fish a week. He continued to endorse this dietary addition and included canned tuna fish and canned salmon in the types of fish that produced this positive effect.

Over the years I heard him lecture at a large annual medical conference held in Broward County and he fretted about the growth of the supplement industry encouraging taking fish oils rather than eating fish. He worried about the warnings against eating all fish to women of child bearing age because of the fear of heavy metal contamination and knew that the fish oils and omega 3 Fatty Acids played a developmental role in a growing fetus and child.

I then attended lectures, in particular one sponsored by the Cleveland Clinic, during which they promoted Krill oil as the chosen form of fish oil supplements because it remained liquid and viscous at body temperature of 98.6 while others solidified. I listened to this debate only to hear the father of the science speak again and this time advocate that one or two fleshy fish meals a month was adequate to obtain the protective effect of Omega 3 Fatty acids. He felt that the supplements did not actually provide a protective effect as eating real fish did. Since I love to eat fresh fish I had no problem with this message but others are not comfortable buying and preparing fish at home or eating it at a restaurant. Supplements to them were the answer.

Steve Kopecky, M.D. examined the question in an article published in JAMA Cardiology this week. He looked at 77,917 high risk individuals already diagnosed with coronary artery disease and vascular disease who were taking supplements to prevent a second event. His study concluded that taking these omega 3 supplements had no effect on the prevention of recurrent cardiovascular events. The study did not discuss primary prevention for those who have not yet had a vascular illness or event.

Once again it seems that eating fish in moderation, like most anything, is the best choice. I will continue to eat my fresh fish meals one or two times per week, not necessarily for the health benefit but because I enjoy eating fresh fish.

I advise those worried about preventing primary or secondary heart and vascular disease to find a form of fish they can enjoy if they want this benefit. If you really wish to reduce your risk of a cardiovascular event; I suggest you stop smoking, control your blood pressure and lipid profile, stay active and eat those fresh fish meals.


More on Shingrix, the Shingles Vaccine

Recently, the FDA approved a new shingles vaccine called Shingrix. It is a two shot series with the suggestion made that the second shot should be taken 2 – 6 months after the first one. Shingrix will replace the original shingles vaccine Zostavax. Shingrix is recommended in all patients over 50 years old.

For those of you who have had the original shot, Zostavax, the new vaccine is still recommended. It is covered by Medicare Part D which means you must take it in a pharmacy or walk in center not in your doctor’s office. While this makes NO sense, it is the rule. If you have had shingles it is still recommended you take the new vaccine (Shingrix).

Shingles is a skin rash and painful skin condition caused by the chicken pox virus Varicella. When you have chicken pox and complete the infection course you are immune but the virus remains alive forever, living in sensory nerve endings along the spinal cord. One third of adults will have an outbreak of this varicella virus which will appear along the path of a sensory nerve or dermatome on one side of your body. It will go through the full cycle of rash, pustule and then scab that the chicken pox did. A significant number of patients will continue to have pain over the involved skin for prolonged time periods in what we call post herpetic neuralgia. The pain is described as severe as an eye scrape, passing a kidney stone or going through labor and delivery.

The original shingles vaccine, Zostavax, protected against the rash 51% of the time and against post herpetic neuralgia 67% of the time. This efficacy dropped to about 30% after four years. The new vaccine, Shingrix protects against the rash over 90% of the time and against the pain syndrome 85-90% of the time while lasting for more than four years.

Only five percent (5%) of patients receiving Shingrix develop side effects. The most common are fever, myalgia and chills. In view of this, I am suggesting to my patients we allow the vaccine to be on the U.S. market for a year to see the adverse event profile and, if safe, we then start the series of shots.

Cigar and Pipe Smoking Significantly Increases Mortality Risk

My male patients express to me on a regular basis their desire to continue to smoke a few cigars per day. They are quick to point out that they do not inhale the smoke like cigarette smokers do. They also point out that their use of cigars is far fewer in number than cigarettes. They all discount the risks of the smoke, its byproducts, carbon monoxide, etc.

The Journal of the American Medical Association (JAMA) has just published a research project which looked at that subject. They followed cigar and pipe smokers from 1985 until 2011 looking at the mortality rate and the cancers they sustained. Of the 357,420 participants in the study, 51,150 died. The death rate of cigar and pipe smokers was much higher than nonsmokers and those who never smoked. There was also a much higher likelihood they would sustain a tobacco related cancer such as lung, throat, esophagus, oral cavity and bladder cancer which would eventually kill them.

It was clear the risks were higher for cigarette smokers than pipe and cigar smokers. As a physician, I will continue to encourage smoking cessation of all tobacco products.

Tobacco smoking ruins your health and kills people. Let there be no confusion about that fact.

Scientists Develop Rapid Susceptibility Tests for Urinary Tract Infections

In my geriatric patients, recurrent urinary tract infections and conditions mimicking them pop up frequently. Patients young and old find it inconvenient to come to the office to provide a specimen to analyze whether or not an infection has occurred and what is causing it. You often need to send the specimen off to the lab to culture the offending bacteria and then wait further for the lab to determine what antibiotic if any will work against that invader. As clinicians, if we suspect an infection and the in-office or clinic urine specimen looks infected, we treat with the antibiotics most likely to cure until we actually get the official reports back from the lab.

An esteemed panel of health care experts has recommended something different -suggesting that when symptoms of a urinary tract infection develop patients be prescribed a three day course of antibiotics without an exam or urinalysis or pre-antibiotic treatment urine for culture and sensitivity. This is all part of the 21st Century movement for less costly, less time consuming, more convenient self-diagnosis and care using your high tech apps to diagnose and treat your problem.

In my patient population many of the elderly patients use so many antibiotics so many times for presumed urine infections that we are often dealing with multi drug resistant bacteria requiring intravenous treatment with complex medications to cure the problem.

Scientists announced recently in the journal, Science Translational Medicine, that they have developed a rapid 30 minute DNA test that will allow us to determine the susceptibility of the offending organism quickly. The successful study has led to the beginning of developing a commercial variety of the test expected to be available in three years. If it works and is affordable it will make outpatient treatment of urinary tract infections far more accurate and efficient.

Large Health System Care in the 21st Century

My 74 year old obese, poorly controlled diabetic patient with high blood pressure, high cholesterol, coronary artery disease, asthma, obstructive sleep apnea has been difficult to motivate to improve his lifestyle and his health. He is bright, sweet and caring but just not very disciplined.

At each office visit we review his medications, review his dietary habits and go through the check list of checkups for diabetic complications including regular ophthalmology exams and podiatric exams to prevent diabetic retinopathy and foot skin breakdown and infection. His spouse is always present and we discuss seeing his endocrinologist regularly and a dietitian who specializes in diabetes care all the time. To no avail, I have suggested seeing a psychologist.

Three months ago, two weeks after his last office visit, his wife self-referred him to our local community hospital Emergency Department for a small ulcer at the base of his toe. He was seen, treated and referred to that hospital’s therapy and wound care center. I was listed as his primary care doctor. He was seen by the ED but I was not called or informed of the visit. He has continued to see wound care regularly but, to date, I have received no notification of the problem, the visits, the ongoing therapy, the prognosis and/or the results.

I became aware of the situation when at the end of a long day an emergency department physician contacted me. “Dr. Reznick, we have your patient here. He was seen in the wound care center earlier today for ongoing treatment of an enlarging diabetic foot ulcer. The podiatrist debrided the wound surgically then put a bandage on it and a fiberglass cast. One hour later the patient called the wound care center complaining of shaking chills and rigors. He was told that no one was available at wound care to see him and was referred to the emergency department. He is currently running a low grade fever of 100.8 with a mild elevation of his white blood cell count and says his leg feels the way it did when he had a cellulitis infection. His blood sugar is 256. He is well hydrated. I plan to culture him up, start him on oral antibiotics and refer him back to you for follow up tomorrow if that is ok.”

I suggested he open the cast, take down the bandage dressing and observe the wound and culture it first. He told me he would call the podiatrist from wound care because he didn’t want to “mess with” the cast.

Twenty minutes later he called back, “The patient is refusing to go home. He wishes to be admitted to the private suites section of the hospital. When I told this to the podiatrist, he said he would come in tomorrow to look at the leg.” I asked the ED physician to cut off the cast and remove the bandage and I was on my way in to see the patient. I asked him if he felt the patient needed to stay. He replied, “The patient wants to be admitted and I do not want him to give me a poor patient satisfaction report, so yes he needs to be admitted. The patient satisfaction report may not be important to you private physicians but it could cost me pay and my job.”

There is nothing like assuming the care of a problem that occurred within a large health care system that is clearly interested in generating revenue for services rendered but not necessarily providing continuity of care and communication with its staff so that the patient is treated well. It is irritating and frustrating to not be included in the health care process but called in out of the bullpen after hours for something that should not have occurred in the first place.

When I arrived in the ED and went down to the patient’s room I was greeted by the patient’s wife. The cast was still on. I paged the podiatrist and reached him ultimately by cell phone. I politely made it clear that I expected him to come in now, remove the cast and take the bandage off so I and the infectious disease expert I was consulting could observe the wound, culture it and make a gram stained slide so we could choose the correct antibiotics for this situation. “Why,” he asked suggesting that the culture would show a conglomerate of multiple organisms. “Because infectious disease will want a culture and a gram stain unless they suddenly have started to operate differently and because it is good medicine.” I took a thorough history using my office notes as well and was disappointed and surprised to learn that although at each visit he confirmed that he was seeing his endocrinologist and spoke to him, he actually had not been to his office in over a year.

The admission process takes well over an hour for me. Writing an admission note and entering orders and medications on the hospitals computer order entry system is slow and cumbersome.

At the completion of the process I walked into the room and reviewed my findings and suggestions and asked if the patient had any questions. His wife had one question. “Three months ago at wound care I showed” the doctors an article about the benefits of using a product called Duoderm on diabetic foot ulcers. I asked if it would be helpful for my husband. They said it would be beneficial but it was too expensive and they were not allowed to use it.” She asked them to write out a prescription for it and she would pay for it privately if they would use it. They refused saying they were not allowed to use non formulary items. I told her I was sorry and suggested that in the future if she runs into a roadblock she should call me.

I admitted the patient to the hospital, cultured his blood and urine and asked for help from an experienced endocrinologist and infectious disease expert with his antibiotics and diabetic care. I returned several hours later to find the cast off, the wound bandaged but no wound culture obtained by the podiatrist from our hospital wound care center. I asked the nurse for sterile gloves, supplies to create a small sterile field and culture tubes when the infectious disease physician walked in and relieved me of the task. We used the gram stain of the specimen to help direct initial antibiotic choices while awaiting the culture results. A subsequent MRI of his foot revealed that the infection had spread to the base of the bone in his big toe. This will now require 6-8 weeks of intravenous antibiotic therapy to try and save the foot.

I had been a patient at the same not-for-profit local hospital several weeks before for an inpatient urologic procedure. When I woke up from anesthesia with an indwelling urinary catheter in place, the surgeon was there to report on the procedure. “It went well “he said, “but the damn cheap products the hospital is supplying us with make it highly likely that the catheter will kink up on you and put you into urinary retention. I should have brought some supplies from my office because this doesn’t occur with the products I buy and the hospital used to buy.” The catheter did kink numerous times requiring intervention and eventually a late night visit to his office for him to change catheters and leg bag so that the urinary drainage was not obstructed. When it is kinked and urinary flow is obstructed and your bladder fills, it is very uncomfortable.

As a board certified internist with experience in geriatrics and hospital staff privileges for 38 years it is disconcerting and frustrating to see the direction of hospital medicine. It is unclear to me if using Duoderm on my patient’s foot ulcer would have prevented his failure to heal and bone infection. It is clear that his wound caregivers thought highly of the product but were clearly intimidated to write a script for it even if the patient paid for it themselves.

It is sad that the ED physician wouldn’t justify his decision to admit the patient to me by simply saying his clinical situation warrants it. To be afraid of patient satisfaction rating as the reason for suggesting he stay is disheartening. To purchase less expensive urinary catheters which the surgeons clearly know is problematic and add pain, discomfort and additional costs for physician and nursing time is inexcusable.

If this is the direction hospital care is travelling I feel sorry for our patient population. I will address these issues with hospital administration and our medical staff officers directly for whatever it is worth.

Telemedicine and Acute Stroke Treatment

My community hospital is holding its quarterly physician staff meeting and one of the items on the agenda will be a bylaw change which will permit outside physicians, not credentialed or vetted by our hospital credentials committee, to perform video consults on patients within our hospital. Hospital administration is pushing this bylaw change, and since there has been a quiet coup which has transferred medical staff power from the community’s practicing physicians to the hospital employed and paid physicians, it is a foregone conclusion that it will easily pass.

The bylaw change is being requested because the hospital would like to continue to reap the benefits of being an ischemic stroke comprehensive treatment center and offering the health benefits to the community despite not being able to meet the criteria. If a patient presents to the emergency department within four hours of developing ischemic stroke symptoms they must be offered the administration of a “clot busting “drug Alteplase (t-pa). The patient must not have any bleeding tendencies and no evidence of active bleeding or a mass or tumor on head CT scan and must be examined by a neurologist within 45 minutes of arrival.

The problem is that most community based neurologists with outpatient office practices and hospital staff privileges cannot and will not drop everything they are doing and run to the emergency department to evaluate a new patient each time a stroke protocol patient arrives. When given an ultimatum by the hospital administration, that they must take call and be available within 45 minutes, our community neurologists en masse relinquished their hospital privileges.

The hospital countered by bringing in several research oriented academic neurologists and neurosurgeons to man the beautiful new Neuroscience Institute and provide coverage of the ED for the stroke protocol. Few if any of these physicians were able to develop and maintain a practice within the community and they have since left. The Emergency Department is staffed by employed board certified emergency physicians who are well qualified to diagnose an ischemic stroke and administer t-pa. They refuse to do so citing the liability of a poor outcome as the reason. Despite data indicating the benefits of t-pa administration in these situations, the 6 out of 100 chances of a bleed in the brain plus the 1 in 6 chance of death is enough to deter their participation.

You would think that since the hospital hires these physicians the logical choice would be to fire them and hire a group that will provide the state of the art care in a timely fashion. This has not occurred. You would think that the state legislature would grant the ED physicians sovereign immunity from medical malpractice suits if the patient meets the criteria for the ischemic stroke protocol and the patient is given appropriate informed consent for the procedure but this common sense legislation has not been developed or passed.

The hospital has chosen a different pathway. They are opting to hire neurologists from a university medical center who will provide video consults on ischemic stroke patients from an offsite location. Robots will actually examine the patient and televise the data back to the telemedicine center after an emergency department physician performs a brief initial evaluation. The neurologist off site will then provide the needed neurology consult to proceed with the injection of the clot buster.

I suspect the mechanism will work like this. A patient or family member will call EMS via 911 and be taken to the Emergency Department. A triage nurse will ask all the questions to qualify the patient for the t-pa protocol; a robot will examine the patient and transmit via TV the data to an offsite neurologist while an ER physician does an exam. A CT scan of the head and brain will be performed. If no bleed is discovered or tumor or mass that could bleed, t-pa will be administered by the pharmacy and nursing staff. Further intervention by an interventional radiologist and or neurosurgeon may then occur.

At no point in this protocol does it call for the patient’s primary care doctor or cardiologist or usual neurologist to be called. We will be called once the procedure is complete because neither the ER physician or the neurosurgeon or the interventional radiologist will want to admit the patient to neurology ICU. While our surgical ICU and Medical ICU/CCU are covered 24 hours per day by an outsourced hired intensivist group, the neuro ICU does not have that type of coverage.

I can hear it now, my phone ringing and upon picking it up I hear the voice of a clerk in the Emergency Department, “Hello Dr Reznick, Dr. Whateverhisorhername wishes to speak to you about patient Just Had A Stroke.” I get put on hold for five minutes and then in a flat nasal voice, “Hello Steve your patient came in earlier by EMS with symptoms of an acute ischemic stroke. They met the t-pa ischemic stroke criteria and were treated. Unfortunately, they had a major hemispheric bleed with mass effect and edema and are now unresponsive and intubated on a ventilator. We need you to come in and admit him and care for him.”

I will vote in protest against this bylaw. I will lobby for recruiting neurologists who are hospital based who will actually see the patient and care for them. I will lobby for a new state law to provide sovereign immunity for ED physicians treating ischemic strokes according to the internationally recognized protocol. I will lobby for our medical and surgical residents on site and in the hospital to be permitted to administer t-pa after meeting the appropriate criteria. I will not support out of the area physicians making the final call and leaving our local physicians to deal with their results.

My First Day on the Job …

There has been a great deal of discussion about doctors’ in training work hours and work load. In June of 1976 I reported to the Jackson Memorial Hospital complex three days in advance of my start date for orientation. I was given a tour of the facility, filled out countless forms and waivers, received my ID badge and was ultimately sent to the Department of Medicine to receive my assignment.

Sitting in the conference room and looking at the patient assignment and ward team assignment list I found myself at the bottom of the list. “Elective Rotation – Steven Reznick MD Neurology.” While all my colleagues in the internal medicine training program left to meet their new residents and meet and learn their patients I was sent to the neurology department in the next building to perform neurology consultations. When I got to the Neurology Office the Chief Resident laughed at me. “Reznick you are on elective. There is no night call. You start in three days. Go home and enjoy your last three days of freedom. Be here at this office at 9 a.m. and we will see what if any consults we have to do.”

Three days later at 7 a.m., filled with anxiety, I arrived at the neurology office which was locked and closed. At 8 a.m. a secretary arrived, showed me where to sit and I waited. At 8:50 a.m. no one had arrived yet on the medical staff and she received a phone call. “Dr. Reznick that call was from your chief resident in Internal Medicine. He needs to see you now in his office.” I asked directions on how to get there and off I went.

The Chief Resident had just completed his three years in internal medicine and was now entering an administrative and research year. He greeted me with, “Reznick I am not sure how you managed to be so unlucky but I have to reassign you from elective to Ward Team III on South Wing 8. You have eighteen patients on your service and you do not have the luxury of three days to learn them. By the way, here is the team pager and you are on call today and tonight.” “How did I get so lucky? “ I asked. “We originally had an anesthesia resident rotating through medicine but he decided after orientation that he did not want to be a doctor so he just left.”

The Chief gave me directions to SW-8, which was at least air conditioned, and off I trudged. Upon arrival I went to the nursing station, introduced myself to the charge nurse and asked if my ward team was around. “They are not back from morning report yet but we need you in 828. The priest arrived fifteen minutes ago and they are waiting for you to terminate life supports.”

My first patient was 28 years old with widespread metastatic terminal breast cancer. After multiple seizures from brain metastases and an unsuccessful CPR attempt she was “brain dead” on a ventilator. Her family had chosen to terminate life supports and my role was to walk in, disconnect the ventilator and pronounce her dead when she stopped breathing. I walked in, introduced myself, shook hands all around and listened to the family talk about my new patient. When it was time the nurse and priest walked to the ventilator and disconnected it with me holding my hands so I did not feel like I was doing this alone. The nurse adjusted the morphine drip and the patient peacefully and calmly ceased breathing. I listened for a heartbeat, felt no pulse, saw no respirations and spoke to each family member and the priest as my pager screeched, “Call 4125 MICU for a transfer.” I found a phone and called. AC, an intern said, “Hi Steve. We are transferring a 23 year old with rhabdomyolysis and acute tubular necrosis (kidney failure) just off peritoneal dialysis with calcium of 16 out to the floor because we need a bed for a younger more salvageable patient. Can you come get him please?”

The charge nurse on SW-8 gave me directions to the MICU and it took me five minutes to walk there. Out in the hallway was a large stretcher with an even larger gentleman on it with two IV lines running almost wide open and three volumes of charts each larger than the Encyclopedia Britannica. There were no transporters or orderlies to move the patients at this large public hospital so I was left to push the bed along the course I had just walked to get back to SW-8. We walked through non air conditioned East Wing which was considerably more difficult pushing a stretcher than on the original trip.

On the way I introduced myself to Frank, my new patient and began to take a history. Poor Frank was a furniture mover who developed a fever and chills while moving a piano up some stairs and, when he got home and went to bed, had terrible muscle pain. He was too weak to get up so he called 911 and was brought to the hospital three months earlier. For some reason his muscles had decomposed due to the infection, heat and bad luck. The dissolving muscle enzymes were like molasses as they passed through the filtration of the kidneys clogging them up and sending him into acute and life threatening kidney failure. He had survived dialysis and infection and was now being bumped out of the unit for a “younger more salvageable patient.”

When I got back to SW-8 and placed him on his bed I sat down with his chart, overwhelmed and considered using the same option that the anesthesia resident had exercised. I was reading and crying when I felt a hand on my shoulder, looked up and my new resident introduced himself. “You have had a tough morning. Let’s go to the blackboard and talk about hypercalcemia and how to treat it. I bet you know far more than you think you do. I have you covered, don’t worry.”

We were almost through his chalk talk and were about to examine the patient when the beeper screeched again. “Please call 4225, the ER. We have a GI bleeder and he is your admission if he doesn’t arrest before you get here.” John, my resident, jumped up and screamed, “Follow me.” He was running full speed, down the stairs and towards the ER. It was a ½ mile run if not more. When we arrived, sweaty and panting for breath we noticed a jaundiced man surrounded by doctors and nurses with blood spurting upwards from his mouth like an oil well that had just been opened wide. John pushed them aside, felt for a pulse and said to me, “Start CPR.” I got up on the stretcher and started compressions with each compression producing a geyser of blood out of his mouth and on to my white coat and clothes. There were no goggles. There was no barrier protection. “Stop compressions, “he ordered. “There is no pulse or blood pressure, let’s call it.” “Time of death 9:55 a.m.” John directed me to the chart where I wrote a brief note, called the next of kin and informed them and then changed into clean scrubs. “We have about an hour or two now before another admission so let’s go back to the floor, finish up with your surviving patient and get to learn the others.”

At 7 p.m., having rounded with me on all my new patients, John asked me if I had eaten all day and did I live alone. I told him I had not eaten anything since coffee in the neurology office and I was married. He suggested I call home and tell my wife that I wasn’t coming home that night. “Let’s get you to the cafeteria, get you some nourishment and let me introduce you to the resident covering you and Dr Homer tonight.” Since I was not assigned to patient care at orientation, I had not been issued meal tickets. I had about five dollars in my wallet so John gave me some of his meal tickets for a meal. John was a saint. My covering resident was his equal. “Pat” called me a “thoroughbred stallion who needed to be brought along slowly.” She gave me her pager number and told me to call her if I got an admission or if I had a patient care issue. The two other interns on our team were excellent. They made me a summary of their patients and wandered home at about 8 p.m.

The time from 8 p.m. until 3 a.m. was a vast blur. There was an admission of an elderly gentleman with pneumonia. It required drawing all his bloods, labeling the tubes and carrying them to the lab. I had to wheel him to x-ray for a chest x-ray (there were no CT Scans yet), obtain a sputum specimen and gram stain it for Tuberculosis. There were the three blood cultures to draw, starting the IV line and antibiotics and of course writing the admission note and orders and dictating them. There were countless calls from nurses about infiltrated IV lines to be restarted, headaches, fevers requiring me to show up and draw blood cultures, family members calling to discuss their loved ones status.

At 2:30 a.m. I wandered into the ER because I was up for the next admission. “Pat” looked at me and said, “Go into the lounge, lie down and take a nap. Give me your pager. If anything comes up I will wake you. You need a nap.” That simple act of kindness and consideration and a 30 minute nap was like a shot of Café Cubano and adrenaline and, when 7 a.m. work rounds began with my ward team back on site with my resident John, I was relatively fresh to face a new day. I passed the pager to Phil, the other intern, as he asked me, “How did it go?” Somehow I mustered up a “No sweat especially with resident coverage from John and Pat.  John is covering you tonight so I expect you will be fine!”

We got very little sleep during my internship (PGY1) and residency training. We worked 100 plus hours weekly. The patients we saw were mostly severely ill and complex. We did all the lab work ourselves in the ER house staff lab. We started all the IV’s, drew all the bloods, and transported the patients ourselves. The work was physical, demanding, cerebral, emotional and exhausting. Every new patient was seen by an ER physician and attending, an intern, a medical student, a covering resident.

They were reassessed at 7 a.m. on work rounds with your resident and ward team plus often the chief resident. At 9 a.m. you presented the new admissions to a faculty member and the entire residency class at morning report. At 10 a.m. you presented the case to your team attending physician on attending physician rounds. This faculty member reviewed the case, examined the patients and wrote a note documenting agreement with the care plan. At noon your resident presented the case to the Chief of Staff at Chief of Staff Rounds. By 1:00 p.m. the problems and decision making had been reviewed and discussed by six or seven physicians. Sleep was not an issue in decision making because we had so many immediate layers of patient decision making reviews.

Our overworked supervising residents for the most part were caring and helped us out if we were exhausted or in over our heads. Our chief residents were available around the clock if we needed extra help.

I do not want today’s doctors to have to work as hard and perform the menial tasks that I was required to do for any reason let alone because I went through it and survived. I do not believe that the layers of supervision and questioning of your decisions allows for sleep deprived errors and mistakes if everyone is doing their job appropriately. I do feel fortunate that I learned to stain specimens and look at them under the microscope and run electrolytes on flame photometers and learn how to set up cultures of blood and urine on culture plates then read them. It taught me the time involved and the limitations of the test plus the margins for error.

I do believe the high volume of severely ill individuals I cared for broke me down and made me a dehumanized efficient machine. I was fortunate that caring faculty built me up and reminded me why I went into this profession to begin with.

Last week a prospective new patient came by to meet me at my office and see if he wanted to join my practice. During the discussion he lifted his shirt and showed me some scars on his abdomen. “You don’t remember me? You gave me those scars inserting catheters to do peritoneal dialysis on me on SW-8 on your first month as a doctor. I remember how frightened you were that you would hurt me or kill me. I was suffering from kidney failure and high calcium after my muscles broke down from an infection. You treated me for six weeks after I left the ICU and transferred me to an acute rehabilitation hospital where I learned to walk again. I live in this area now and I found you on line and want to be your patient again.”

It’s incredible how life always seems to come around full circle!