30 July 2006

Gay Marriage

I tend not to post on "social" issues, not because I don't care but because I don't have any special expertise and because I generally think that my opinion doesn't tend to add a lot to the cacophony of voices out there on any given social issue.

But I'll break my rule just once because in the aftermath of the WA Supreme Court's decision to uphold the WA-DOMA, I have a thought which I haven't heard laid out in just about any other forum.

First of all, some background. I tend to view the ability to marry the partner of your choice as a fundamental human right. I think that expanding the institution of marriage to monogamous gays is hardly a threat to the Republic, and in fact would probably strengthen the institution of marriage (as well as innumerable families). I look forward in hope to the day that my gay friends will be able to participate in this important social ritual.

But in all, I think it is probably a good thing that, at least in Washington, the court did not impose a requirement for the admission of gays to the ranks of the married. Don't get me wrong -- I was terribly disappointed when the ruling was announced, and though I am no legal scholar, it sounds as if the justices were not able to come up with any rationale for their decision, but just punted back to the legislature. From a strictly strategic point of view, I think this is good.

Why? Because Washington is a pretty blue state, but also highly polarized, as are so many states. Imposing by judicial fiat the requirement for gay marriage, would play into the conservatives' game plan of decrying judicial activism and liberals' undemocratic governing practices. Worse, it might provoke a backlash strong enough to propel an anti-gay-marriage amendent to the state constitution to passage, which would be a disaster. This ruling, however unwelcome, forces us to go back to the legislature, and even to the people, to educate and persuade them that gay families deserve to be married, too.

It's harder, and will take longer. It will be uglier, with "debates" where bigots use code words and misdirection to try to defeat us. But in the end, it will be better. Social change is best effected by persuasion and consensus, rather by an authoritarian dictat. And given the state's political composition and current social trends, I have no doubt that we will be successful. It may take years, but once we win, it will be a clean win, with much less fear of any backlash-provoked take-back.

Punting

Number one rule of blogging: When your muse fails you, publish some jokes.


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You know it's going to be a bad day in the ER when...

The paramedics in the parking lot are all using mops to clean up their ambulances and the EMTs are using a hose.

You show up for work and notice bars have just been installed on all the windows and there is now a metal detector at the hospital entrance.

It's the first day for the new medical interns, paramedic and nursing students all at the same time.

The off-going shift has a hard time keeping a straight face when giving report, especially about Room 15.

Your next five patients and their families all scream at you in different languages, none of which you speak.

Your next patient screams at you in a language you do understand, but you can't remember hearing that many obscenities strung together at once.

Your next patient has maggots but isn't dead.

The intoxicated 275 lb. transvestite in Room 15 keeps trying to get your home phone number because you "are just too sweet."

The hospital's attorney wants to talk to you but her secretary won't tell you what it's about.

The hospital has a surprise disaster drill. You were the only one who wasn't tipped off.

Your first patient of the day insists there is no way that she can be pregnant. She's crowning.

The Department is completely empty and one of the off-going shift says, "It's been that way all night, hope you have a quiet day!"

You have writers' cramp and still have 7 hours of the shift left.

In the middle of a disaster drill two real trauma patients present themselves.

The psychiatric patient who thinks he is Jesus was placed in the same room as another patient who thinks he is Satan.

No one remembered to buy coffee.

The paramedics who offered to go out and pick up lunch (and coffee) just advised over the radio they have witnessed a motor vehicle accident involving a transit bus versus a minivan. "Stand by for update."

You get a subpoena for a lawsuit a on a patient that walked out of the department against medical advice two years ago. You can only hope that is what the attorney wants to talk about.

The Hospital Administrator left you a cryptic message about a news crew showing up "sometime today to do a little filming, so everyone act natural."

The psychiatric patient's delusions are beginning to make sense.

The paramedics tell you the patient you just received with a closed head injury, flail chest, and positive belly tap is in "much better shape than the one still being cut out of the minivan."

25 July 2006

Rhetorical Question

Jon Stewart to McCain yesterday:

"President Bush has been very clear that, through his leadership, he has made the world safer. My question to you is simply this: how much safer can the world afford to have him make us?"

16 July 2006

Grateful for the anticlimax

As an ER doc, you are supposed to really live for the bad cases: the crashing patient, shocking the heart, intubating, flinging drugs like an ubermensch, heroically stamping out disease and pulling lives back from the abyss. You're supposed to ride the adrenaline as naturally and instinctively as the surfer rides the wave. Our friend charitydoc perhaps epitomizes this unselfconscious id-like personality that is supposed to be the fundamental characteristic of the ER doc. And truth be told, it's not all myth -- most of us in the ED do get off on the excitement and adrenaline.

But sometimes, you're just not up for it. You're tired, or got in a fight with the wife, or for whatever reason, just can't really summon the enthusiasm for the event. But that doesn't stop them from coming in, does it? Much though you might like to close the doors and turn off the lights, the ambulances still bring you the business. So there's nothing for it but to put on your game face, stand up straight, and head into the room as the paramedics bring in the next customer. It's not too hard, really. After so many years, it's almost a pavlovian response.

So tonight, near the end of my shift, after I had already seen 30 patients in 9 hours, which is unusually busy even for me, the radio crackled to life. The report started a buzz at the nursing station:

"Infant, male, newborn, found floating in the pond. Code 3. ETA 5 minutes."

Oh, this does not sound good. More details came over: Baby, just a few hours old, umbilical cord still attached. Found in a local pond inside a white plastic garbage bag tied with a knot. Someone who lives on the pond heard some commotion and managed to fish the kid out and call 911.

So we get ready, call NICU, I review the neonatal resuscitation algorithm in my mind as we pull out the warmer and await the medics' arrival. I am not looking forward to this. I can see it now, a cold blue floppy baby. Will they have a line? I can't remember the last umbilical line I started. They probably have an airway already -- the local EMS is very good at that. These are always grim. I wonder in advance how long we will have to go through the motions before we can in decency call it.

To my surprise, the medics come in with a pink, squalling infant. Cold, to be sure, with a rectal temp of 83 degrees. But otherwise fine, with a brand new clamp on the ragged stump of umbilicus, vigorous, and warming up rapidly. Glucose good at 96. The NICU team shows up moments thereafter, and in no time flat, the kid is lined, labbed, x-rayed, and bustled off to the NICU. Babies withstand hypothermia wonderfully; the plastic bag probably prevented drowning and helped the kid float, while the cold water initiated the dive reflex and help put his brain into hibernation. Amazing.

So I wander back out to the near-desolate ED and pick up my stack of incomplete charts. It's funny, sometimes as an ER doc you feel a little cheated when you have a crash case like this that turns out to be a false alarm. You get your game face on for nothing, as it were. But in this case, I feel only relief. Relief that I didn't have to go through the excruciating dance that precedes the formal declaration of a baby's death. Relief that the child is well. Relief that some mother, who in her desperation and fear threw away her newborn baby, is not now a murderer. I wonder if they'll find her? The police have been here and the media have already called. I can't help but feel bad for her, even though she did a monstrous thing. What sort of straits must she be in to try to drown her infant? I cannot imagine.

I finish my charts, go home, and kiss my sleeping boys goodnight.

13 July 2006

Bias in hiring: good or bad?

As I mentioned yesterday, I am looking at a lot of CVs right now. It's pretty well-known that as a prospective employer, you shouldn't ask about age, maritial status, children, religion, etc.

So, "How old were you when your daughter had her bat miztvah?" is right out.

But a lot of applicants will put that info on their CV. It shows that they're willing to talk about these forbidden topics, and helps humanize the CV and make it more memorable.

Today I spoke with a guy who put prominently on his CV that he was an "Active Member of the LDS church."

I thought that was interesting and a little gutsy. Mormons (or LDS, as I guess is preferred now) are a religious minority that . . . don't always get good press. I've heard many of the less than positive rumours about their faith. I am utterly personally uninformed about their religion on a factual basis, though, and will say right up front that I am completely unqualified to form an opinion about the LDS church or Mormons in general.

Except that I have known a lot of Mormons. And if I were to attempt to draw a conclusion from the n=8 that I have personally known, some very well, it would be that they are the nicest, most friendly and caring, open and honest people I have ever known. Without exception. I can't reconcile the really nice LDS people I have known with the dark rumblings I have heard about their church, so I don't even try.

So it's interesting that if the knowledge that this applicant is LDS were to evoke any bias in me, it would be a positive one. It's neither here nor there, though, since what I need is not a cleric, but an ER doctor who can move the meat, and he seems to be a stellar candidate. If his references check out, I srongly expect to hire him.

12 July 2006

Playing with people's lives

You'd think, just from working in the ER, I'd be okay with the heavy weight of responsibility. You'd think I'd be used to the fact that the things I do have a big impact on the lives of the people I see and care for. But it's not really so. You see, ninety percent of the people I see, on average, are perfectly fine, or only chronically ill, or ill but in a really obvious way that is easy to fix. The remaining ten percent are a challenge, and it's a little scary, like treading in a minefield, trying to figure out who they are. But mostly I get it right, and mostly the cases that go bad were not my doing, but the consequence of some bad disease. So even when someone dies on me, though I feel badly, I don't exactly feel responsible. The point is that barring a really great, tricky diagnosis, or a remarkable fuck-up, 99% of my patients will get better or worse regardless of what I do.

But now I am engaged in a process that will take people out of their homes, uproot their families, disappoint and devastate some, and elate others. It will impact 100% of the individuals I am seeing.

We're hiring.

And I am the lucky soul that gets to do all the hiring. It's completely up to me. I get to review the CVs, conduct phone interviews, check references, bring them out for a tour and meeting, and make the final decision. I hate it.

We're a good ER group to work for. We are in a desirable location, independent, democratic, and have a good payor mix. No sooner had I put the word out than I had 20 CVs, maybe half a dozen of which were competitive. I have been conducting the phone interviews first. It's painful listening to these candidates go through their paces, hearing them try to communicate to me how they really are a great ER doctor, hearing how badly they want this job, trying to interact on a collegial, personal, human level, while remaining impassive and reserved with my comments. I hate liking several of them and knowing in the back of my mind that I am unlikely to hire him/her. I hate having a 'get to know you' chat and not being able to ask about their marital status, kids, religion, or a host of other personal data that usually informs one about a person. But mostly I hate being in the position of sitting in judgment on these people.

It's funny. Those who know me will attest that I am the most opinionated and judgmental person they know. But it's easy to be judgmental when there are no consequences to one's judgments. Powerlessness is a sort of freedom, when it comes to opinions. But now I am going to make several people fly thousands of miles for a two to four hour interview, then I will get to choose the lucky ones who will have the opportunity to sell their homes, pull their kids from school, and move to our neck of the woods. And if I have chosen badly, I'll get to fire them in a year.* And I get to tell the other contenders that, thanks for playing, but you are not a good enough doctor, a good enough person, nice enough or smart enough or well-bred enough to come work for us. I've been on the other end of rejection often enough to dread those phone calls. (can I do it by letter? It seems very wrong.)

There's an up-side here -- we will, at the end of the day, have some new partners, new colleagues to work shoulder-to-shoulder with, new peers and maybe even new friends. So I shouldn't be so down on the process -- it is really a great opportunity in its own way.

But it is in its way much harder than the clinical work I routinely do. Which is a little remarkable.


* Not that I would anticipate such an occurrence. But it has happened in the past, and is incredibly painful. A personnel mistake is so hard to undo. The potential consequences weigh very heavily on my mind.

07 July 2006

Workin' for a livin'

Light blogging these days. I'm in the middle of a stretch of working 14 out of 16 days. Yeah, ouch. Sadly, in all those shifts I haven't even seen any cases interesting enough to blog about. At least none that I remember . . . I'm getting a little slap-happy.

Also, we got Civilization IV. Which is taking up all my free time. So that also is getting in the way of blogging.

Never fear, I'll be back, just as soon as I save Kyoto from Ghandi and his rampaging hordes!

02 July 2006

A Short Life, A Great Love

Luke over at Cancer Dad shares an amazing story about Benny Petz, who recently lost his battle with Neuroblastoma. Thanks to Benny's parents for sharing their intimate story. I can't imagine in the slightest what they went through, and I grieve for them. As Luke said, we should honor their bravery by reading and sharing their story. You can read it at the Arizona Daily Star, but have some Kleenex on hand before you click over. It's a raw emotional tale.

While you're at it, send some positive thoughts to a wonderful little boy who is fighting his own Neuroblastoma. Nathan just turned six and has been living with NB for three years. He is a sweet and loving child. Send him and his amazing family some love.