If you are starting the think you might be depressed, or that your brain is out to kill you, here’s what you do…

The following is an “unrolled” Twitter feed from Mark Reid, MD on depression.  It’s solid, important advice that I thought should be shared. Dr. Reid  is an internist from Denver, who is very active on Twitter as @medicalaxioms. He is also the author of Medical Axioms, a delightful book of medical wisdom

Interview with Dr. Reid about @medicalaxioms

If you are starting the think you might be depressed, or that your brain is out to kill you, here’s what you do:

1. Find or call your primary care IM of family MD. When you call for an appointment and they ask what for, say “depression.” Notice how the scheduler doesn’t flinch. They get this call 4 times a day!

2. When you get to the doctor, and they ask what’s wrong, just say, “I want you to do those screening tools on me to see if I’m depressed.” Let them do their thing. If they say you’ve got it, let them tell you how meds and counseling work. Let them tell you what they know about pills and which one might help you. Decide together if pills are worth a shot. Tablets really work for some people.

3. You also need a counselor. Ask the MD for a referral. That might work. If not,

4. Go to your insurance and find out their preferred providers for counseling. I suggest you pick someone your same gender. Counterintuitive for some but works better for many.

5.  If that doesn’t work, go in the internet and type in counselor or therapist and the name of your town or city. Read ratings and reviews. Cross reference them with yelp. Look for someone nearby who writes a bio that sounds okay. Figure you’ll see them once a week and it will cost $100. Give them 4 tries. If you don’t feel like you are getting anywhere, ditch them and try again. I’ve seen 3 people in the last 10 years and in retrospect I can rank them.

6. With tablets and shrinks, the trick is resolve. If they aren’t working or give side effects, don’t just quit. Try again. Different shrink. Go back and try a different tablet with your MD.

You can feel better and you are worth it. You deserve it.

There’s lots of other stuff that helps some people: support groups, sobriety, exercise, sleep hygiene, self help books, spiritual practice, ALANON. If your shrink is any good they will recommend this stuff and know something about it.

Photo credit

To add a few more comments to Dr. Reid’s advice….

  • Depression is a disease, not a failing. You wouldn’t judge yourself for a sprained ankle.  This is the same…. except for one thing.  The disease of depression includes not being able to objectively see what’s going on.  That’s why it’s so important to get started on treatment.
  • If you are a medical student or resident, counseling is available for you and it’s free. The same rules hold, though.  If the first person you see isn’t helping after 3 or 4 visits, it’s ok to make an appointment with someone else.  This is not personal and you don’t have to worry about “hurting their feelings” any other consequences.
  • The National Suicide hotline is 1-800-273-8255. You are loved.  You matter.  This is a disease not a failure.  Please seek help.

Photo credit

 

 

Ebola, Personal Risk and Our Trainees

Around the world, Ebola and other infectious diseases take the lives of mothers, fathers, sons and daughters … and place at risk those who care for them. This risk is known to all who choose medicine as their career.  It is part of caring for the ill, and always has been.

PlagueDoctor

Photo credit

 A healthcare provider has an ethical and professional duty to address a patient’s needs, as long as the patient’s diagnosis – or when the patient’s initial complaint, on the face of it – falls within the provider’s scope of practice. Refusing to do so is not consistent with the ethical principle of beneficence. “ Twardowski, et. al. RI Med Jl October, 2014

Around the world, physicians, nurses, and all healthcare workers willingly fulfill their duty to care for patients who are or might be ill with Ebola and other dangerous diseases, reflecting the altruism and compassion of those who choose medicine for their career.

Emory patient

Emory Nurse ‘Could Not Be More Proud’ of Those Treating Ebola

Ebola doctors

Ebola doctors sacrifice all to bring hope.

However, the duty to care for these patients does not automatically extend to those who are learning medicine.  Without the experience, context and well developed skills of established providers, trainees are potentially at greater personal risk.

When I operate on patients with HIV, Hepatitis, or any blood-borne pathogen, I take every precaution possible for myself and the staff who are scrubbed. I also take advantage of the “teachable moment” to discuss ethics and universal precautions with my trainees…. but I don’t allow medical students or junior residents to directly participate in the case. Likewise, I am sure that learners will not be allowed to provide direct care for patients known to be infected with Ebola or other dangerous diseases… or to travel to West Africa for clinical experiences while the epidemic is still present.

ebola2

Photo credit

All of us in medicine honor those who provide care to the ill despite the risk …and we thank you for the example you are setting for those learning to heal.  We hold our colleagues in Dallas, Atlanta, Africa and around the world in our thoughts as they work tirelessly to heal the sick and contain this terrible disease.

grieving doctor

Photo credit

Here’s a list of aid groups working on the Ebola crisis — and how to donate

Top 10 ways to survive (and maybe even enjoy) being on call

Like our residents (but not nearly as frequently), my group has started taking “in house” call.   For every one who is currently or has been a resident, this is an experience we all know…. and one that’s hard to describe to those that haven’t experienced it.   Spending 24 hours on call in the hospital can be emotionally and physically draining, but it has moments that make it a special experience, too.

There are ways to make the experience easier.  Here are my top 10 ways to survive (and maybe even enjoy) being on call:

1. Drink water. Put a water bottle in the lounge refrigerator, drink from every water fountain, put your water bottle next to your computer, or come up with other ways to stay hydrated. If you want more flavor, bring a zip-lock with cut up lemons or limes to put in your water or add a splash of fruit juice.

2. Be kind. No matter how stressed or busy you are, knock on every patient’s door and enter their room with the intention to help. Sit down or put a hand on their arm when you are talking to them. Smile.

3. Take breaks. On purpose. No one really expects you to work non-stop for 24 hours and it’s not good for your patients. Deliberately stop to do something else every few hours, even if it’s just for 5 minutes. Go outside for a few minutes for a short walk to catch some natural light and breathe some fresh air. Get a good cup of coffee or tea, listen to some music or just sit. If you want something more active, climb a few flights of stairs, stretch, or even do a light workout.

4. Eat well and eat often. Do not rely on fast food or the hospital cafeteria. By far the best plan is to bring really good food from home. You need to have “comfort” food on call. If you don’t cook, buy really good prepared food that you can look forward to. Make sure you have “plan B” ready if your call day gets completely out of control by having an energy bar (my favorite is Kind bars), peanut butter sandwich or other “quick” food in your white coat pocket.

5. Be part of the team. Notice and encourage the unique camaraderie you share with everyone else who is on call. It’s a small “band of brothers” who find themselves in the hospital at 3am. Be kind to each other, help each other, and use this unique opportunity to get to know someone you might otherwise not get to know.

6. Wear good shoes. If you are in house for 24 hours, bring a second pair that’s completely different (clogs and running shoes for example). Ditto socks. Buy really good socks and change them after 12 hours if you can.

7. Use caffeine wisely. It’s practically essential for many of us at the beginning of the day, but beware trying to “wake up” with caffeine after 2pm.   Not to mention that if you “caffeinate” all night, you’ll have that sickly post-call-too-much-caffeine feeling in the morning.

8. Take naps. Any sleep is good sleep on call. If it’s possible, 20 minutes will make you more alert and effective in your work.

9. Make your beeper a “Zen bell”. Use your pager or phone as a tool for mindfulness. When it goes off, take a deep breath, relax the muscles in your face and shoulders and be present.  This is a proven practice to decrease stress – try it, it works!

10. Learn. Take advantage of the unique educational opportunity of being on call. The fact that there are fewer people around at night and on the weekends has a real impact on how and what you learn on call.   If you are a student or junior resident, you are more likely to be the first person evaluating new consults and admissions. You are also more likely to have one on one time with your senior resident or faculty as you care for patients together.  If you are further along in your training,  the “down time” on call (if there is any!) is a great time to catch up on reading.

 

 

The Hospital Never Sleeps – And Neither Do the Patients

I recently spent the night in the hospital with a friend who underwent a minor procedure.  It was a fascinating experience to watch the hospital “from the other side”.  Overall, I was very impressed  – the nurses, patient assistants, technicians, clerks and food service personnel were universally professional and kind.

But then we went to sleep…. or tried to.  Vital signs, meds, and necessary events were more or less over for the day by 10pm.  The unavoidable noise in the hall, unfamiliar bed, and the events of the day made it difficult to get to sleep, but we both drifted off around midnight.

At 4am there was a cheery “Sorry to bother you, but I’m here to get your weight”.  She couldn’t have been nicer but when I asked why my friend had to be awakened at 4am (!) for a weight (!) she responded, “We have to have the weights, labs, x-rays and vitals all completed before the day shift starts at 6am.”

Not too long after this experience, I admitted a long-term (and adored) patient of mine for an elective procedure.  Her parents reminded me that last time she was admitted I wrote an order to forgo the middle of the night vital signs so their daughter (and they) could sleep.  Coming on the heels of the night I spent with my friend, it made me think about how we manage sleep in the hospital.

 night-shift-nurse1

Image credit

Why do we wake patients up to weigh them?

There are patients who absolutely must be woken up for medical reasons.  If you are admitted for a hypertensive crisis, you need to have your blood pressure checked during the night. Waking patients up in the middle of the night for things that could easily be accomplished during daytime hours is done for three reasons, none of which are medically necessary:

1) To distribute work to the less burdened night-time staff from the day time shifts

2) To have the data available for morning rounds.

3) Because of pressure to get the patient out of the hospital at a certain time

Is there really no way to off load the busy day time shift without waking up patients?  Would it really change things if stable patients (particularly if they are on monitors!) were allowed to sleep through the night?  Would it change therapy if the daily weights were at 10 in the morning instead of 4 in the morning?

There’s no question it’s nice to have data for morning rounds – but is it really essential?  How much of this is a holdover from the paper chart era? In the era of the electronic medical record, access to data- at any time of the day or night – is easier than it used to be.  Granted, morning report or rounds would be different, but I think it’s something we could figure out.

There is financial (and other) pressure to get patients out of the hospital.  But have we looked at ways to manage this that don’t involve waking up patients?  For example, there are hospitals that count the “day” in the hospital by the patient census at midnight.  As long as you are out of the bed at midnight you don’t get charged for the day.

 

Sleep is important for recovery from illness or injury.

There are numerous studies that suggest that the immune system in particular is affected by disruption of sleep.  The data are not conclusive, but many physicians, nurses and scientists have published work suggesting that protecting sleep for ill or injured patients might be important:

Sometimes it’s not about the patient.

In babies with necrotizing enterocolitis, we order abdominal x-rays every 8 hours for at least a day or two (to look for air in the abdomen.).  If the x-ray shows “free air” (like the one below), it means they need emergency surgery to deal with the perforated bowel.

NEC-perf

The standard schedule in our hospital for q8 (every 8 hours) x-rays is 6am, 2pm and 10pm.  Here’s the problem with that schedule as far as hospital efficiency goes:

  • The 6am xray, if it shows a problem, will result in action around 7.  If the baby needs surgery, the operating room is already set up for the 7:30 cases.  Because the OR schedules is usually very full at the beginning of the day, we often then have to “bump” (postpone) a patient to do this emergency case.
  • The 2pm x-ray will result in the surgery being posted around 3,  a complicated time in the OR since day time nursing staff is leaving and the remaining cases are being juggled.
  • The 10pm xray will start the process rolling at 11 or so – putting the surgeon in the OR in the middle of the night.

Since the timing of the x-ray has a big effect on the timing of the surgery, it becomes a variable that really affects what happens. Here’s what happens if you change the schedule to 3am, 10am, and 8pm

  • The 3am xray, if it shows a problem, will result in action around 4. Surgeons are the early-birds of the hospital. Since they will be waking up early anyway, the case can easily be started at 5 or 6, which helps with the OR schedule and keeps the surgeon from being up all night.
  • The 10am x-ray will result in the surgery being posted around 11 – this is a time when “holes” in the OR schedule are easier to find, and getting the baby into the operating room will be easier.
  • The 8pm xray will start the process rolling at 9 or so – which means the surgeon is more likely to get some sleep.

getty_rm_photo_of_nurse_yawning_over_paperworkPhoto credit

What’s the bottom line?  We don’t think about some of the unintended consequences of our orders.  Sleep is important – for both patients and the people taking care of them. It’s worth thinking about.

The Best of Wellness Rounds 2011

HAPPY NEW YEAR TO EVERYONE!

Advice for interns

Why I hardly ever drink diet drinks

How to choose your specialty

What to do on your day off

Studying basic sciences – strategies for success

Studying clinical medicine

Getting (and staying) motivated to exercise

How to succeed on clinical rotations

Gifts for medical students and residents

Why I’m spending more time on Twitter

How not to have sore feet after a day in the hospital

Shoes to Wear in the Hospital

I got home recently after a 14 hour day in the operating room with (predictably) a pair of really tired feet…. which lead me to think about shoes, foot rubs, and the fact that no one ever talked to me about this in my training.

What kind of shoes should you wear in the hospital?

There’s a lot of walking in the hospital, but there’s even more standing.  Running shoes don’t provide the right kind of support for standing, which means your feet will suffer if that’s what you wear.

It goes without saying that you should not wear open toed shoes in the hospital.  It’s not only against the rules, but it’s going to gross you out one day.

Basic concepts to choose good shoes for the hospital

Look for good support.  The classic “nursing” or “operating room” shoe exists for a reason – they are designed to provide the support your feet need during long days of standing and walking.

I have recently become a huge fan of Allbirds. They are amazingly comfortable, incredibly light and even after a long call night my feet really don’t hurt.  The website says they can be washed in the washing machine which is obviously a big plus, too!  Other comfortable shoes you might try include  Clarks, Rockport and ecco.

Photo credit

 

If you will be standing for long periods on rounds or in procedures, think about getting shoes that slip on and off.  When you are standing for a long time, being able to slide out of your shoes becomes important.  If you’ve been standing for hours, it really helps to stretch your calves and change the pressure points.  It’s also easier to step out of your shoes all together and stand barefoot for a little while.  When you are sitting, you can slip them off and let your feet breathe. Dansko  professional clogs are expensive but they are the “classic” OR clog..  Sanita clogs are supposedly now made in the original Dansko factory, tend to be a little less expensive and are also loved by many.  Birkenstock or Clarks clogs are alternatives to consider, too. Crocs are tempting but have poor support, minimal ventilation and have been banned in some hospitals.

Try to get shoes that breathe.  Examples include Merrell’s Encore Breeze (a great OR shoe) or Allbirds.  These shoes are not only comfortable, but they can be put in the washing machine (minus the insoles) if they get really dirty at work.

Once you’ve met those criteria, lighter is better.

Long days standing at work also make for stinky feet.  Just like long-distance runners, you have to learn some tricks to deal with this.

  1. Have more than one pair of good shoes and alternate them.
  2. Don’t buy cheap socks. Wicking socks like Balega socks are worth the price.
  3. Take an extra pair of socks with you for long days and change them in the middle of the day.

Foot massage, pedicures, and other foot care

After work, in terms of “bang for the buck” there is nothing that will make you feel better than a little attention to your tired feet.

Use a good foot scrub in the bath or shower like Bath and Body Toe the Line of The Body Shop’s peppermint scrub .

Take 10 minutes and try some methods to soothe tired feet.  If you are lucky enough to have a significant other who will rub your feet … congratulations!  (and, by the way, it really is “true love”…)

Even if you are a guy – don’t blow off pedicures.  If you’ve had one… you know.  If you haven’t… try it before you decide.

My Back Hurts…

Back pain is very common during medical training.   All doctors spend time leaning over beds …. some of us (e.g. surgeons) more than others.  Back pain for most physicians is about core fatigue.  When you lean over for any length of time you are supported by your core muscles.  When the core muscles begin to fatigue, you transfer the job of holding the position to your joints (spine, hips, knees) and the muscles of your back.  So – the most important way to prevent or get rid of back pain is core training.   Crunches alone won’t do it – they just work the muscles in one direction.  What causes our pain is twisting with bending over.  You need a set of exercises that strengthen your core in more than one direction.  A great way to strengthen your core (if you have time for the classes) is doing yoga, pilates, or tai chi.  But (assuming you don’t really have time for classes), commit to 5 minutes a day of core exercises and I bet you’ll see a difference.  Needless to say, we’re talking about “ordinary” back pain here.  If you have symptoms of radicular pain, weakness or paresthesias go see a doctor!!!

Here’s some urls with good illustrations of functional (i.e. all directions) core exercises

http://www.mayoclinic.com/health/core-strength/SM00047

http://sportsmedicine.about.com/od/bestabexercises/a/all_abs.htm

One other really important thing – make sure you use a good technique if you have to lift a patient (or any other heavy object) i.e. face the object (no twisting) and use your legs, not your back.   http://www.webmd.com/back-pain/lifting-properly-to-prevent-back-injury

For surgeons, you can do a few things in the operating room that will help.  This list is from an article I published last December (Am J Surg. 2009 Dec;198(6):742-7. PMID: 19969123)

All surgery

  • Set the table height at the level of the umbilicus of the tallest assistant/surgeon and use standing stools for all other personnel

Open surgery

  • For long cases that require torsion of the back (pelvic surgery, head and neck surgery), change positions often; raise or lower the bed slightly; switch sides; and stretch periodically

Laparoscopic surgery

  • Place the monitors so they are directly in front of the operating surgeon/assistant, the goal is to avoid any twisting of the neck for the surgeon or assistants
  • Place the monitors in laparoscopic surgery slightly below eye level (15° is best) to have a slight head-down gaze
  • Use enough standing stools to provide a large enough platform for foot pedals (2 deep, 2 wide if necessary)
  • Once the trocars are in place, lower the table (or add standing stools) so the operating surgeon has relaxed shoulders
  • Avoid positioning foot pedals so the surgeon has to stand on one foot; even better, switch to the most ergonomic possible hand control