Monthly Archives: January 2013

The Doc is Thinking Chili for the Superbowl

I’m excited for this Sunday’s game.  Well, not really for the game itself, but for the menu.  Don’t get me wrong, I enjoy football.  I just don’t feel any particular allegiance to either of the teams playing in this year’s big game, so while I know I’ll appreciate watching the skill of the players, I won’t have that much interest in the final outcome, which kind of makes for somewhat dull watching.  Therefore, my plan is to focus primarily on the commercials and the food.

We’re having a few friends over, and I’ll be serving chili and cornbread, along with various other munchies.  Chili is a huge hit in my house – my husband and boys get really excited when they see that I’m purchasing ingredients for it.  And they specifically really love my chili, which totally does good things for my ego.

I don’t think I had ever made chili until I had a super-yummy version at a friend’s house.  There was cinnamon in it.  I had never thought to put that type of spice into a tomato-based dish.  I was intrigued, and it prompted me to experiment boldly with the flavors and spices that simmered in the pot when I made it myself.

I cook a lot.  My whole family cooks.  We love food.  We love how it tastes, how it smells, the textures, the colors, the thrill of experimenting and creating, how it makes us feel to feed people, pretty much everything about it.  And (surprise, surprise) I personally get a great deal of satisfaction out of making yummy stuff that’s healthy.  I really love being able to feed people without guilt.

Which brings me back to my chili.  First of all, it’s very low fat.  I either make it with super-lean beef, ground turkey breast, or no meat at all.  I always use tons of beans (mainly kidney beans, some black beans, and when going vegetarian I will sometimes add lentils), so it’s super high in fiber and protein.  I use several cartons of chopped tomatoes, and a lot of onions and garlic, so it’s got plenty of vegetables.  The next part is where I don’t want you to roll your eyes and walk away:  I don’t add any salt, and I use low sodium broth.

Americans in general consume way too much sodium.  We’re used to the taste of salt in certain things, and chili is one of them.  But in the years since I’ve developed my chili recipe, I’ve never had anyone complain, ask for a salt shaker, or not have seconds (or thirds).  Here’s the trick:  Give the taste buds so much to think about that they don’t even remember to look for salt.

The original recipe that I got from my friend called for a bunch of cumin.  I like cumin, but it’s one of those spices that asks to be accompanied by salt.  And I don’t like an overpowering cumin flavor.  So I cut that down a bit.  I went much bigger on the cinnamon, and ran with the theme of spices you would normally think of when baking Thanksgiving desserts.  I upped the chili powder, played with the oregano proportions, and generously added some other goodies from my baking/spice cabinet that brought an exquisite depth and complexity to the dish.  Some of my culinary creations are decidedly mediocre, but I put all modesty aside when talking about my chili.  It rocks.

I have very few secrets, but at this point in time I still don’t share my recipe.  I think the main reason is that by keeping it to myself, if someone is in the mood for it they have to see me and spend time with me – it keeps me needed (but don’t worry – my family knows where it’s written down, so if I die the chili will live on).  So if you’re feeding people this Sunday, try making a pot of “liquid gold,” as my husband and kids call it.  Open your spice jars, hold different jars next to one another, smell the combinations, see what speaks to you, and go for it.  Don’t be timid when you add the flavors – chili is not a subtle dish.  And next post, I’ll give you my cornbread recipe – it goes great with the chili.

Response to Critique of Chapter 1 of “Your Hospital Guide”

I have to admit, I love receiving positive feedback.  It makes me feel like I’m on the right track, doing the right thing, being helpful, etc..  But the concerns and suggestions I receive help me to improve at a much quicker pace, propelling me to better communicate my thoughts.  A non-perfect critique prompts me to re-evaluate and re-think things in a more intense way than just re-reading my own words and listening to any kudos that have been tossed my way.

I received a phone call yesterday afternoon from a close family friend who is a retired Ob/Gyn physician.  This man is a remarkable doctor, beloved by his patients, and he managed single-handedly from halfway across the country to keep me sane through a significant scare during my pregnancy with my third child.  I have the utmost respect for him both personally and clinically.  When he started the phone conversation with “I’ve been reading your blog, and I want to talk to you about something you’ve written in your book’s first chapter,” I listened very closely.

His concern was specifically, “Don’t allow perfection to be the enemy of the good.”  He agreed that having someone with you in the hospital is extremely important, but is afraid that people will read my advice to have someone there at all times and if they are not able to do so, may give up on the idea of a Hospital Buddy completely, or not understand the most important anticipated times to have someone there.  Some of those most important times include when a person is medically unstable, when someone is having surgery or is post-surgery, when procedures are being done, and when medical teams are rounding.  And I am extrapolating from his concern to think that after taking to heart my advice, perhaps someone might avoid going to a hospital when needed because they do not have someone to go with them.

So as I do my final edits of my book, I will work in the above thoughts.  However, I am going to have to take my seatbelt analogy a bit further here as I work in those thoughts.   I don’t want to water down the force behind my original exhortation to try whenever possible to have round-the-clock Hospital Buddy presence.

You are most likely to be involved in a motor vehicle collision when you are in an intersection.  Certain intersections have statistically higher rates of collisions.  Collisions happen more frequently in icy conditions.  If you had a finite number of seatbelt hours, you would make sure to buckle up on an icy day while driving on a two-lane country road without shoulders.  You would buckle up when going through the intersections in which accidents were most frequently featured on the evening news, and try to click your belt through most intersections in general.

This may end up providing you with enough protection.  It is certainly better than never wearing your belt.  Problem is, depending on your speed, road conditions, and general traffic patterns, you may hit intersections at times that differ from what you had anticipated, and you’ve got your belt on too early or too late to cover the actual crossing.  It doesn’t account for the metal trash can that blows into the road in front of you, the car door that opens into traffic, the oil slick on a clear day, or the wasp that flies into the car.

So the best thing to do is to have your seatbelt on at all times, and you should do whatever you can to do so.  When you have only limited seatbelt time, you should try to have it coincide with your statistically most hazardous driving time.  And when you have to drive somewhere because you are fleeing from immediate danger, and the car does not have seatbelts, you should drive anyway, keep as alert as possible, and accept the potential risk.

If you are on a business trip in a city where you don’t know anyone, and you develop appendicitis or have a heart attack, don’t avoid or delay going to the hospital because your wife isn’t with you.  But your wife or brother-in-law or friend should drive into town as soon as possible to join you.  If you break a hip and have hip replacement surgery planned for tomorrow and your sister is only available to be with you for 24 hours, have her come in for the surgery and the time immediately following.  But if you can think of a friend who might be able to be with you until then, and someone to be with you after your sister leaves and at the time you’re discharged home, call them.  And when you have an elective, non-urgent surgery, test, or procedure coming up, plan it during a time when people will be able to be there with you.

Please keep your comments, feedback and questions coming!  I appreciate all of them immensely.  And Dr. Ronnie, how do you feel about my sending you my full manuscript this week for a second opinion?

“Your Hospital Guide” Part 5 (of 5) of Chapter 1 (Always Have Someone with You in the Hospital)

Choosing your Hospital Buddy/Buddies:

Who should be your Hospital Buddy?  You should be accompanied by someone you trust to take accurate notes for you, someone who will speak up for you and question people when necessary, and who is able to put up with you when you are in a less-than-perfect-health-induced crabby mood.  It should be someone with whom you are comfortable sharing medical information.  It also should be someone with whom you have discussed your general medical goals and wishes, including what you would want done in a life-threatening emergency (if this person is not your legal medical proxy (someone to whom you have given the legal authority to speak for you in a medical situation if you are incapacitated), he must know who your legal medical proxy is and how to reach that person).  This person could be a spouse, partner, family member, friend, or a hired Hospital Buddy (there are private nurses available for hire, as well as trained non-nurse hospital companions who can especially be helpful overnight).

It is tiring, both physically and emotionally, for someone to be your Hospital Buddy.  Therefore, you might want to line up a few people, if possible.  This will enable people to take turns, so that everyone has a chance to get home (or to a local hotel) to shower (guests are not allowed to use patient showers), sleep, and attend to any other urgent matters.  If the hospital stay is only for a couple of days, then one person should generally be adequate.  If the hospital stay stretches beyond two or three days, it helps to call in the reinforcements, even if only for a few hours each day or a few overnight shifts.

When people to whom you are not close enough to ask them to be your Hospital Buddy ask what they can do to help, request that they help hold things together at home.  If your Hospital Buddy is your spouse or someone else you live with, ask a neighbor to take in your mail and take care of your pets.  If you have young children, have a friend, family member, or trusted adult babysitter stay with them so that your spouse can be with you.  Other help-offerers can be asked to bring dinner the first few nights you’re back in your house.  The more people you allow to help you, the less pressure you’ll feel like you’re putting on any one person.

“Your Hospital Guide” Part 4 (of 5) of Chapter 1 (Always Have Someone with You in the Hospital)

My hospital has specific visiting hours.  Won’t the nurses kick my Hospital Buddy out?

What about visiting hours?  In general, most nurses are lenient about allowing people to stay beyond designated visiting hours, provided visitors are quiet and considerate of roommates.  With resistant hospital personnel, your best bet is generally a calm, well described explanation of how your/your Hospital Buddy’s presence is actually assisting the nursing staff (help with keeping the person comfortable, assistance with getting to the bathroom, bringing a person water, general psychological support, help remembering details when communicating with doctors, etc.).  Getting permission from your doctor is also extremely helpful, as it can help avoid objections from a later shift of hospital staff who might not be familiar with your Hospital Buddy system.

It is much simpler to have a companion stay overnight when there are private patient rooms.  In a private room, there is generally more space for a convertible chair or a cot.  When there is a roommate in the picture, there can occasionally be resistance from a roommate’s family or from nursing staff to overnight Hospital Buddies, and this is best dealt with ahead of time, with permission from your attending physician.  Make sure you address the hospital staff’s concerns (e.g. you will keep noise levels low, you will respect a roommate’s privacy, you will keep the cot/sleeping chair as out-of-the-way as possible), be as polite as possible to the hospital staff, and remember to thank them for accommodating your request.

Why is it even an issue to have someone stay overnight?  And why are there ever limits on visiting hours?

When you understand the objections to overnight visitors, and the reasoning behind visiting restrictions in general, you can easily address any concerns, and are much more likely to obtain the permission that you require.

The short answer to why you need to argue for overnight stay permission is that the hospital is trying to ensure a restful environment for all its patients, and visiting hours tend to be noisier than other times.  However, it is more complicated than that.  The information in the later chapters of this guide (in the section describing “The Places,” which is currently slated to be Section 4, but that could change) will help you to understand many of the factors that play into how a hospital functions, and you will be able to use this knowledge to advocate effectively.


“Your Hospital Guide” Part 3 (of 5) of Chapter 1 (Always Have Someone with You in the Hospital)

If the person being hospitalized has memory difficulties, even when they are medically rock-stable, there should be a Hospital Buddy with them 24/7.

What about an elderly patient or a patient with memory issues?  If the person who is hospitalized has dementia, it is always best to have a companion stay in the hospital overnight.  It is very disorienting to wake up in a hospital, and many patients end up being sedated or restrained due to overnight confusion (Note: overnight confusion is sometimes refered to as “sundowning”).  The best way to prevent or minimize this is by having someone in the patient’s room at all times so that a companion may gently remind the patient where he or she is, help keep the person from getting tangled in any cords or IV lines, and help keep the person calm.  At night, the person’s Hospital Buddy can remind the person that it is nighttime, and that it is time to sleep.

Many times in a hospital, the nurses deal with “problem patients” (those who are awake and confused overnight, and who might fall from bed, pull out i.v. lines, or otherwise pose a danger to themselves), by rolling their beds down near the nurses’ station overnight.  While this allows hospital personnel to keep a closer watch on these people, it also means that the patient is kept in a light environment through the night, with people talking and walking around, which keeps the patient fully awake.  This contributes to a vicious cycle of a person’s having a disturbed sleep/wake schedule, worsening confusion and contributing to delirium.  It is much preferable for these people to have a Hospital Buddy available to stay with them in their room.

In certain circumstances, a hospital may have a “sitter” – an official person hired by the hospital – sit at a person’s bedside to verbally orient the patient when necessary, and remind the patient not to get out of bed.  However, there are not always enough sitters available for every patient who might benefit from having one, the sitter is generally not someone who is familiar to the patient (and thus may not be as easily able to calm the person, who is feeling confused and disoriented in an unfamiliar environment), and many rehabilitation and nursing facilities will not accept a patient who has required an official hospital sitter within the past 24 hours.

What’s wrong with using restraints and/or sedation? 

While these may, at times, be necessary to ensure a person’s safety, there are risks involved with their use.  A person may respond unpredictably to a sedating medication – older patients, in particular, may be more likely to become over-sedated, even with lower doses.  Physical restraints are generally unpleasant for the person to whom they are applied, and restraints may cause a person physical injury.  And again, there are many nursing homes and physical rehabilitation facilities that will not accept a patient who has required restraints in the past 24 hours, which can complicate a patient’s discharge from the hospital.  While a physician may determine in certain situations that the risks of sedation or physical restraints may be outweighed by the risks of not sedating or restraining a person, it is best to try to set up an environment in which those measures are less likely to be necessary.


A Little More Jazz

This is a follow-up to the musical analogy from my last post.  A hospital functions like a jazz ensemble.  Intricate, intertwining, indispensable parts come together to form a unified, breathing, well-oiled whole.

The nurses play the role of the bass.  The bass is the heartbeat of the ensemble.  You don’t necessarily notice or think about the bass, but you feel it deep inside.  It’s actually what you dance to, what you tap your foot to, and what you bounce your head to as you listen to the music.  The bassist sets the overall rhythm, stepping out at times to solo and demonstrate the profound foundation the instrument provides along its range of deep beauty, and then brings back steadiness to the piece.  You cannot do without a bassist.  You cannot do without the nurses.

The internists, pediatricians and family practitioners are like the trombones.  Trombones are in the middle of everything.  They slide from high to low and back as they maintain the steady middle ground of each piece.  They harmonize, and tie together the sounds of the other instruments.  The trombonists provide the backbone for the other brass and the woodwinds.  Their range is wide, and they function across their range to blend the treble and bass sounds to coordinate the overall flow and sound of the music.

Saxophonists are sexy, and a little bit cocky.  Kind of like surgeons and obstetricians.  They solo frequently, and have incredible manual dexterity.  They’re a little showy, and with good reason – they’re really good.  They open the piece, close the piece, and take the piece on fantastic rides throughout.  Have you ever watched a saxophonist solo?  They tend to move with their instrument, leaning and thrusting their bodies into the sound almost in a “Dirty Dancing” kind of way.  It’s very physical.  They are fully immersed and sure of what they’re doing.  Like you have to be when you’re gowned, gloved, masked, and cutting into a person.

The specialists come in like the trumpets: loud, sure, and precise.  They can make a statement playing the same note repeatedly, and then when you think you can anticipate their next sound, they jump pitch, leap back and forth, and add a brilliant flourish as they bring the narrative of the musical story to another level.  You want them to weigh in on a subject.  When they speak, you listen.  And they know what they’re talking about.

The social workers and the respiratory, speech, physical, and occupational therapists fit the role of the electric guitar player in the jazz ensemble.  The guitarist has unique style and technique, filling in and enhancing the melodies and rhythm.  The guitar licks punctuate the storyline, adding layers that before you heard them, you might not have realized were missing, but once they’re there, you realize how important they are.

A drum set encompasses the behind-the-scenes people within the hospital.  The snare, like the clerks and secretaries, takes the lead in moving things along at a reasonable pace.  Each drum in the set has to beat in exquisite coordination with the others, fulfilling basic roles and ensuring that the rhythm and tempo proceed as they should.  The scurry of activity within each drum fill takes the musical piece to the next spot.  You’re not sure what just happened, but you liked how it sounded and you know you’ve shifted.  There’s a lot of complicated action.

The pianist sets the tone of the piece, like the administration of the hospital.  The tone can be soft or harsh, bright or dark.  You hear it louder at some times than others, but it is always there, affecting the overall mood.

The individual musicians in the jazz ensemble need to practice and hone their skills.  Each section needs to function together, and while each section speaks out and sounds great, you can’t listen to any one subgroup by itself for too long without its getting a little annoying.  You need the balance of the different facets of the ensemble playing off one another.  The entire group needs to practice together, listening to one another and adjusting as necessary to achieve an overall sound that is mind-blowing in its complexity, flawless in its integration, and simply beautiful.

And with that, we will return in the next post (on Monday) to your regularly scheduled installment of Your Hospital Guide.  I hope you’ve enjoyed this brief musical interlude!

Jazz – A Break from the Book

My residency director, a not-at-all-old-but-definitely-wise man, used to compare the practice of medicine to jazz.

When people think of jazz, they think of improvisation, of unconventionality,   Maybe a little free-form, or rule-breaking.

Turns out, jazz is extremely structured.  And precise.  To be a great jazz musician, you’ve got to be cemented firmly in the basics, and from there, within the structure and precision, you solo.  You improvise.  You break the rules.  And it sounds fantastic.

And then the director tweaks things.  Interprets the music.  Each musician interprets, but they all have to be on the same page.  And then the solos!  They soar, they glide, they travel to the moon and back, but not at all randomly.  They follow over specific chord changes and progressions, overarching rhythms and key changes, and they crescendo and decrescendo, hang on one note or travel a chromatic scale, jump intervals in various tempos as the soloing artist sees, hears, and feels where the line of sound should go.

I think about music a lot.  I gave birth to three musicians (I seem to recall that each one came out playing an instrument).  Right now, I have the distinct pleasure of being with my oldest son in Grand Rapids, Michigan for a few days as he participates in the Michigan All-State High School Jazz Ensemble (third chair trumpet – yay, Zac!).  As I listened to these amazingly talented young musicians playing together for the first time on Thursday, I realized how fundamental the basics are to the output of the sound.  Were it not for the precision, the tightness, the structure of this language of music that these kids speak so well, it would sound cacophonous, rather than the delight it is even early in their first hour of rehearsal.

When my residency director compared the practice of medicine to jazz, he did it to hammer into our heads that we had to have a firm foundation, built on medical knowledge, able to speak the language, and then we could add the art, the gut feelings, the off-label prescriptions – in short, the solos.  As time has gone by, I’ve seen that the analogy goes deeper.  Music, and especially jazz, lives within its interpretations.    A doctor needs to speak the language of physiology, pathology, and statistics, and needs to then interpret the studies that come out, and apply them to the actual practice and decision making.  What is that study actually saying?  Does it fit with my patient?  It sounds ok now, but how would it work if I sped it up here, slowed it down there, and added a key change right here – would that make the difference between my patient’s stumbling along this rhythmically tricky path and her gliding gracefully through the measures to a finale of good health?

I plan one follow-up post to this jazz theme, and then I’ll return to the chapter 1 installments of Your Hospital Guide. 

“Your Hospital Guide” Part 2 (of 5) of Chapter 1 (Always Have Someone with You in the Hospital)

Aren’t my doctors and nurses there to advocate for me or my loved one?  Of course, but they have many other patients to care for (your nurse usually has three to seven other patients, unless you are in the intensive care unit, and your hospitalist generally has 12 to 20 or more other patients along with you each day).  It is beneficial to your healthcare providers to have someone knowledgeable about you there.

So my nurses and doctors are busy.  What could my Hospital Buddy really do for me?  Do they really need to be there at all times?

Your Hospital Buddy can remind your doctor that the last time you had a fever and started seeing pink elephants, you had a urinary tract infection.  Or your buddy can point out to your nurse that normally you are quite sweet, and the fact that you are cursing at the nursing staff is a severe, sudden personality change, for which you should be medically evaluated.

Doctors arrive in patients’ rooms at random times.  Your Hospital Buddy will be able to take notes for you while you are napping or sedated – just make sure to scribble a permission-to-talk note for the doctor, so that your doc can speak to your buddy and fill him or her in on what’s happening.  As you write down your daily list of questions for your doctors, you can decrease the stress of worrying about missing your doctors’ visits when you know that someone you trust has that list and will ask and record the answers for you.  You can nap, when necessary, with peace of mind.

What about at night?  Again, it is always safest to have someone with you.  Your companion is there in case of emergency.  Occasionally there may be an instance when someone remains in the hospital simply because they are awaiting a procedure that has been scheduled, or are finishing a course of intravenous antibiotics, but otherwise are rock-stable, and then it may be reasonable not to have someone stay overnight with him.  However, when things are rocky, it is still preferable to try to have a companion.


“Your Hospital Guide” Part 1 of Chapter 1 (Always Have Someone with You in the Hospital)

Chapter 1 – Always Have Someone with You in the Hospital

This is possibly the most important piece of safety advice for a person who needs to be hospitalized.  This chapter explains why it is so important, what this person can do for you, and who this person should be.

No exceptions.  Well, very few exceptions.  A hospitalized person will benefit from having a non-hospital-personnel person with him or her at all times.  We’ll call this person your “Hospital Buddy.”  Like your swimming buddy at summer camp, this is a person you choose and who chooses you, who accepts the responsibility of looking out for you, who enjoys your company, and whose company you enjoy.  As a camp counselor would never let a person out into the lake without a buddy (they would have a person “triple up” with someone rather than let someone in the water alone), you should not allow yourself or your loved one to be in a hospital without a buddy.

Redundancy is routinely factored into systems to ensure safety.  If one safety measure fails, the backup measure kicks in.  Your car has brakes, and it also has seatbelts to keep you from being thrown from the car if your brakes fail to stop you in time to avoid hitting the deer that runs in front of your car.  Your alarm clock has battery backup.  Your house-wired smoke detectors have battery backup.  Your Hospital Buddy is your backup safety mechanism, and a hospital is simply not a place to be without backup.

I’m a perfectly intelligent, capable person.  Why do I need a backup?

As was mentioned earlier, a person in the hospital is either quite ill, or is undergoing something that has potentially serious side effects or complications.  A post-surgical patient may be groggy from anesthesia or from pain medications, and may very likely not be able to think appropriately.  Similarly, a sick person may very well not be in the clearest state of mind.  Chemotherapy can sometimes cause unpleasant reactions – exhaustion and severe nausea and vomiting does not put someone in the best frame of mind to absorb complicated medical information.  A woman who has had an uncomplicated pregnancy and has just delivered a healthy child may begin to bleed and may not be in a state to understand a potential need for emergent surgery.  Someone needs to be there in the hospital to cover for you when necessary.

If it turns out that there are no acute events requiring your Hospital Buddy to step up as your backup, then you will at least have had some company, and someone to bounce things off of when you had decisions to make.  It is never a waste to have had the necessary backup on hand.  If you make it home from the grocery store without an accident, you generally don’t say to yourself, “What a waste it was that I had my seatbelt on.”  Similarly, when you arrive at work on time, you don’t usually lament the fact that your alarm clock battery wasn’t used last night.  Your Hospital Buddy is your seatbelt, or your battery backup.  He or she is your personal advocate in a place where you may very well need an advocate.


Getting into “Your Hospital Guide”

Few things are more stressful then being in the hospital.  The very fact that a person is there means that something frightening, serious, or potentially dangerous is going on – otherwise that person wouldn’t be in a hospital.  Scary statistics about medical errors are frequently spotlighted on the news, friends have probably regaled you with tales of their own medical horror stories, and you may have some horror stories of your own.  To top it off, when you need to be hospitalized you are likely imagining every possible thing that could go wrong.

Read this guide early, preferably before there is even a thought of hospitalization for you or a loved one in the forseeable future.  Use Your Hospital Guide as a general educational tool to familiarize yourself with the environment, culture and personnel of these medical institutions.  If you or someone close to you is going to be hospitalized, take a deep breath.  You can maintain a fair amount of control in a hospitalized situation.  Your Hospital Guide will help you work with doctors, nurses, therapists, and other hospital personnel to get the best care possible for yourself or your loved one.

Your Hospital Guide is divided into sections.  Section One: First Things First, includes the introduction, which provides a brief overview or “tour” of the book, as well as a chapter elaborating on my most adamant piece of advice to you: always have someone with you in a hospital.  It also has a chapter that briefly discusses the subjects of advance directives (who you want to make medical decisions for you if you for some reason become unable to do so yourself, and how you would like those decisions to be made) and code status (a written order that specifies whether a person is to be resuscitated in a medical emergency if they stop breathing or if their heart stops), since hospital personnel will ask you about these when you are hospitalized, and you should understand them.

My next book posts will convey content from this first book section.  I hope you find the content helpful and informative.  Please leave comments to let me know what you think, and please ask questions!