Friday, June 26, 2009

'Royal Pains' review delayed

Episode 4 aired last night, and ordinarily I'd have watched it by now, but Monday is moving day, so we're up to our necks in boxes and things to do. Early next week should be about right. Take care!

Thursday, June 25, 2009

The Fun Begins

As I said a while back, I had to take, and pass, my national certifying exam before I could call myself a PA-C (for 'certified,' as though that were not already obvious).

The test was Monday. I answered my 360 questions in under four hours; hey, I was on a roll. And this morning I got my results. I'm official.

Friday, June 19, 2009

'Royal Pains' ep. 3: Strategic Planning (but not very much, or very well)

Okay. So, the pilot was enough to get me interested (well, that and the marketing assault on Facebook and Twitter). Last week, there were glimmers of hope in terms of how Divya, the PA character, would be presented. In this, which appears to be the second episode written/ filmed but the third one shown, there were several 'facepalm' moments. Consider it one step back after last week's two steps forward, which means in other words that I agree with the decision to show these out of order. Bottom line: if this had been on last week, according to my lovely wife, she might not have been watching last night. I would have, because I'm an old man and I enjoy yelling at the TV.

A + denotes something I liked, and a - is so much more than just a bullet point-style dash.

In the opening bit, Hank is trying to get Evan to go for a nice cardiovascular system-exercising run, while Evan is trying to a) scope chicks and b) get Hank to admit their new enterprise should probably involve caring about money, just a little. While trying to make a questionable point about how dogs and women are somehow the same, Evan causes a dog-walker, who is otherwise minding his own damn business, to be bitten in the hand by one of his charges. Rather than stomp Evan into a coarse paste of hair gel and poor judgement, the kind-hearted dog walker (whom I want to call "Benny," and will since IMDB is no help today) apologizes. Hank, being Hank, looks at Benny with soulful eyes, says "I'm a doctor," and mumbles physical exam findings. Yup, that's a dog bite, all right. Pretty crappy exam, though.

+ Hank quite rightly says Benny needs to get to the ER for 'a thorough cleaning' instead of stitches. We don't sew puncture wounds.

+ It's good that Hank pokes holes in his water bottle and squirts the jets into the wound to clean it (a little, anyway). Research shows that the two main things that prevent infection are 1) using A LOT of irrigation, and 2) having a little pressure behind it. So just unscrewing the cap and dumping it would be, according to some research, less helpful.

- On the other hand, there were like 8 or 10 holes in that thing, which means the effect is lessened... and lots of the water was nowhere near the wound. And of course, whatever's left in Hank's 20-ounce bottle is of almost no help. Would have been easier to just hold the guy's hand under a drinking fountain or a simple garden hose for a good 10 minutes.

- And the number one question Hank would ask, as a real-life Emergency doctor: "When was your last tetanus shot?" THAT'S the reason he needs to go to the hospital.

After this B plot is safely sailing, some more silliness occurs. Further evidence that this is actually the second episode comes in the form of a conversation with Boris. Later there will be scenes between Hank and Jill that completely ignore what we saw last week in the 'real' episode 3, and a conversation between Hank and Divya that bears (scrawny, shriveled) fruit last week, which would have been 'next week.' Honestly, I'd have preferred they leave this one in the drawer, show us Episode 4 now, and call it good. But I'm getting ahead of myself.

Hank and Divya arrive on the scene of this week's "Privileged D-bags Who Are Actually Not That Bad Once We Understand Them Better." I'm going to call them PDB's, for short. On the way in, Hank gets Divya to confirm the info I previously had as a rumor, which was that she somehow went to two to three years of PA school, for 8 to 12 hours a day, without her family catching on. Oooo-kay.

I can't decide if this is a Screw the Midlevel moment, because Hank recognizes Divya's smarts and talent, saying she's "qualified to work at any of the major clinics in Manhattan." Instead, I think this is meant to be her big defining conflict for the first season. I'm already looking forward to the scene where Brian George appears as Divya's strict and demanding father, whose heart melts when he realizes what a strong and capable woman his little girl has become. And sort-of-almost a doctor, too!

And then we meet the PDBs. Momma-PDB is a driven, icy matriarch who is focused with such laser-like precision on her family's success that she neglected to develop a third dimension to her character. Her offscreen husband is a former Fed director and current US Senator, but not the President, and therefore is a total failure. Good Son PDB somehow bears his mom's pathologic orchestrations with good humor, perhaps by doing drugs or appearing in drag shows in the city every few weekends (either of which would be far more interesting than what actually happens). Daughter PDB is as high-strung as Mom, as bland as Good Son, but is blonde. This must be offscreen Dad's contribution. That, and a slow-burning irritation with The Way Things Have Always Been that will result in a totally unsurprising confrontation later.

Seriously, the first time she tries to object to something, Mom lays down the law, and closes with her wacky catchprase " that okay?" we already know about 75% of the dialogue for that inevitable scene. Which will of course have to happen today, and which will of course feature Hank standing nervously nearby, because he needs to, House-like, catch the one key phrase that randomly blows the whole case wide open.

Okay, here's the deal. I have advanced training in medicine, but I also have a degree in theatre. And I'm here to tell you, this writing sucks. It smacks of unused bits from the pilot and random scraps from pitch meetings past. For the rest of this week, I'm going to try to stick to the medicine, so as not to get too depressed here. Oh, I'll be watching next week, and I'm sure it will be better. Because it can't help but be.

+ I was amused at the medical equipment in the PDBs' former 'game room.' Hank and Divya might have a clue how to operate maybe half of that stuff. Mostly, the 'executive physical' line made me smile (since I've been to two of the Mayo facilities, and that's kind of how patients are encouraged to think sometimes), and idea of a yearly head-to-toe physical done as an action montage! was loopy fun (for me, because I'm weird).

- Why the eff does a healthy 18-year-old need a treadmill stress test, or even an EKG in the first place? Must be a college athlete thing, hey? And what, no hernia check? That's easy comedy gold right there! An echocardiogram is always a nice visual. And sweet zombie Jesus, where did Divya learn phlebotomy? That looked like a two-inch, 18-gauge needle attached to nothing in particular she was jabbing into the patient's AC.

+ Need to check your patient's vision, but don't have a Snellen chart? Yeah, there's an app for that.

+ Later on, after Good Son PDB gets really sick, really fast, for no good reason, they'll do a spinal tap. He'll be in fairly poor position, and they'll take out a whole lot of fluid, assuming the vials we don't see are as full as the one we do. But props must go to the writers who refer to there being four of them, and which tests to do on each.

- And, um, -SPOILER ALERT!- part of that executive physical would be looking in the ears the way they checked the eyes. AUTOMATIC FAIL for not seeing the deer tick suctioning off Good Son's football awesomeness drop by drop through his ear canal.

- Wait. It would have been a good idea to get him to a hospital earlier, but now he's too unstable to move? What did you do in there, Dr. Hank? And in the pilot, after you opened up Tucker's pericardium with common household materials, you remembered that the helicopter is a flying ICU. What, now that you're staying that's not good enough? Wow. You've changed, dude.

- Divya. Yo, Divya! Hey! Look, thanks for pre-oxygenating the patient before the intubation (holy crap, you did have the O2 hooked onto that thing, right?), but now that the tube is in, it would be helpful if you a) checked the end-tidal CO2 thing, b) listened to make sure the tube is in the trachea, or at least c) BAGGED A LITTLE MORE SLOWLY. We're not trying to get this guy overinflated or alkalemic. Air has to go in and come out. Where did you go to school, again?

But eventually, the offending parasite (literally, not any of the PDBs) will be removed, and everything will be cool. And this being the Hamptons, Hank has not actually just wasted tens of thousands of dollars on a workup that would be obviated by looking in the patient's ear, because the money was already wasted when Momma-PDB bought the equipment. So I guess that's a win, in terms of the larger health care system.

I'm not talking about the fastest-developing case of hot tub folliculitis ever, because Evan was an embarrassing 80s-movie cliche horndog this week, and I'm not sure if those girls were supposed to be over or under 21. Everything about that plot was creepy and weird. "Hey, girls! We're hanging out with a skinny loser we just met, but his house is nice! Let's do body shots... off, um, each other maybe? I guess? I really didn't think this through, but don't worry because USA Network wouldn't make us actually do it, so long as we say 'body shots' a couple times! Wooo!"

+ Grudging props are however given for the line "I tried all day to convince these girls I wasn't a douchebag, and they all went home smelling of vinegar and water." I have an uncomfortable feeling that the entire plot worked backward from this line, but what the hell. It was funny.

At the end, there's a heartwarming scene where Hank earns a gold star for the first part of this exchange:

Hank: So we should talk about your title...

Divya: What's wrong with 'Physician Assistant?'

Hank: Well, people tend to just hear the second part of that.

My heart swells, I get a little misty, and I hug a throw pillow to my chest. "Oh my god," I think, "the writers of Royal Pains really understand me. And they... they like me." Hank continues:

Hank: I was thinking more like, 'Associate.'

And, y'know, fair enough. There are plenty of people who would prefer 'Physician Associate' to 'Physician Assistant,' and indeed back in the very earliest days of the profession, the former term was actually the one that was used. And people really do trip over the 'assistant' part. It's true that no, we are not independent practitioners (and don't really want to be), but we are professionals. We practice medicine too, and our job really isn't following the doc around, fetching stuff, or answering phones. It's practicing some of the medicine, so the doc can concentrate on his or her own part of it.

But for better or worse, Divya's license says 'Physician Assistant,' and so does her Master's degree. She can be "Hank's associate in the practice" and a PA at the same time. It would be far better if she would stop saying she's "Hank's Physician Assistant" (even to the point of inserting a word into the phrase "Hank's assistant") because that's just as confusing.

But whatever. They just started working together. As time goes on, he'll understand how well-trained she is, and how good her skills are. She'll learn (mostly medical) stuff from Hank; he'll learn (mostly Hamptons survival skills) stuff from her. Eventually, Divya will show up for calls herself, and get Hank involved on those cases where she recognizes she needs the backup or additional expertise.

Maybe. If the show turns into a more interesting (and more realistic) direction. I still have hope, but wow, this was not the episode to show to people who want to check it out for the first time. This one was a C+ all the way. It might have been a B-, but having seen what they can do, I know they either weren't trying here, or else they were trying and failing to illustrate some point about Hank being out of his element, the team needing to learn to work together, or something. The acting was fine, but writers just failed to have a decent plan.

Friday, June 12, 2009

"Royal Pains" Ep. 2: There Will Be Food (and potential)

So, there's a new summer show on USA. It's on after the ridiculously enjoyable Burn Notice (which is itself kind of a mix of The Rockford Files and a Bourne movie), and worth checking out. But what's germane here is that Royal Pains features a PA character, the first on American prime-time TV since Jeannie Boulet on ER way back when.

Given the show's premise -- talented Emergency Med doctor's career goes boom when hospital beaurocrats throw him under the bus after a hospital trustee dies; he falls into being concierge doc to the spoiled rich in the Hamptons -- I was curious how a PA would fit in. The pilot showed us Divya Katdare, a sharp young woman from a wealthy family who apparently wanted her to be an MBA instead. This being New York, I'm assuming she's RPA-C (since they use both the R for 'registered' and the national standard '-C' for certified), but it's not like they're showing us close-ups of the characters' business cards.

Last night was only the second episode, so I have many questions, hopes, dreams, and fears when it comes to how this all might play out. It would be pretty sweet to have a PA as a major character on a popular hour-long drama. Likewise, considering all the annoying misperceptions there are about the career, this new show could wind up part of the problem. So I'm watching, carefully.

So much so, in fact, that I decided I'd take a page from Scott, MD over at Polite Dissent, and do a weekly write-up of the episodes, evaluating them for medical as well as narrative quality. He does it for House, and it's a great read every week, whether or not you are a medical person. Put a bookmark there, and check it out whenever you've just watched an episode and wonder "wait -- does it really work like that?" (The short answer is, probably not, but like I say, Scott's site is about enjoying the details.)

So I basically watched Episode Two in liveblog fashion: I fired up the DVR this morning, took some quick notes, and proceeded to pick things apart. There's good stuff too, so annoyances and errors are denoted with + or - for bullets.

* Hey, new pre-title voiceover to set up the plot. Wow, we really do love Burn Notice, don't we?

- Would it kill the producers to have Hank say "Emergency doctor" instead of "emergency-ROOM doctor?" Not that it's their job to correct every little misconception, but I don't see the benefit to perpetuating them. Whatever. Last week, he was not only EM trained but also did a fellowship in toxicology.

- Um, hey, you don't need an MD to examine a wound or take out sutures. Divya could totally handle that; but I see, having Hank present in that scene was important to the story, so that the crew could be invited to the party. I'm going to count these instances of "Screw the Midlevel" as we go on through the season. They could just as easily have had Hank walk up to Divya finishing the suture removal, with Tucker saying something like "naw, I just wanted to see if you felt like hanging out." This not only doesn't screw the midlevel, it fits the whole "Tucker needs a dad" thing.

- That wound looked okay, if a little too red at the medial aspect, but the sutures looked like crap. Apologies to the props person or set medic who gamely threw some stitches into a piece of moulage putty, but ya should have gotten some better reference photos. That looked like it was done by a Navy Seal under fire. On his own abdomen.

+ The actual title sequence, with trippy underwater stuff and backwards-cam, was pretty cool on first viewing. I wonder about all these cheap stethoscopes in the promo materials for the show, but maybe you'd have to pay 3M or something if everyone rocked a Littman like in real life.

+ Evan gets all the best lines. As a temporary Chicagoan, I laughed out loud at "ketchup is for dillettantes and three-year-olds." My wonderful, lovely wife puts it on everything, and I mock her for it.

+ "You need some blood work. I'd love to have my associate Divya do a full workup." Holy crap! They do understand what PAs do... unless they think she's a phlebotomist. But no, let's give the writers some credit here. Divya would, according to Hank, draw the blood, get the lab to do the appropriate tests, and then interpret the results. Which is true. But then, that makes instances of "Screw the Midlevel" that much more notable. Okay writers, you're officially having it both ways. (I'm doing that gesture where I point to my eyes with two fingers, then turn them around to point at you.)

- You do realize that 'I get blackout drunk on those rare occasions when I drink' is still kind of a red flag, right? I mean, nice plot device and all, but Hank is so concerned about everything, all the time...

+ Hey cool. Andrew McCarthy is Cary Grant as C.K. Dexter Haven from The Philadelphia Story. I love that movie! ...Oh, no, wait. He's an ass. And a very well-done "that guy is an ass" scene it is, too. Yowch.

+ I'm really enjoying not only Evan as a character, but what Paulo Costanzo is doing with it. The cooking/dancing went on a little too long, but it won me over. Although, how long did that food sit out if the ballerina wasn't coming over until after sundown? I also really liked when he admitted that NYC had gotten stale for him, which sheds some additional light on his drive to get Hank to the Hamptons last week.

+ The "Robin Hood of medicine" thing, as illustrated by Hank's speech on Bill's boat, is an appealing fantasy. Gosh, if only more of us could just draw fat checks from random rich people, and give our services away to the rest of our patients!

+ The running gag where Hank never, ever, gets to eat a bite of anything (until the end, sharing Chinese food with Jill) was cute. In the ER, nothing makes more work appear like ordering or heating food.

+ Hey, House writers: see how it works? A character who understands physiology sees a patient go into shock (shock being defined correctly as "perfusion insufficient to meet the metabolic needs of the patient"), looks at the heart monitor, and then identifies it as 'cardiogenic shock.' A little clunky and over-exposition-ey, because 1) who really cares at that point, and 2) duh, but still. Divya clearly knows medicine. This is nice, because as of now I trust the writers to know she's not a medical assistant, even when they treat her as one. (Caveat: I haven't seen this reaction to gluten, and I'm a little skeptical it would clear that quickly. Also a three-lead portable monitor isn't a Holter, and come to think of it I never saw them put pads on the patient, but since so much of medicine is boring we give some slack on these matters.)

- People, we never shock a flat-line. That TV trope has to go. Draw up the epinephrine or atropine, but put down the paddles and back away.

Overall, this was a nice solid A- of an episode. I'm feeling generous since while things are still very new, I'm seeing more to like as more is revealed about how the writers and producers approach the characters and the medicine. The show is finding its equilibrium between commenting on how "the system is broken," presenting its version of what's both cool and important about the practice of medicine, and keeping the story moving for its characters. My PA-touchstone character got zero development in this episode, but on the other hand she displayed some competence and knowledge. I'm feeling a Divya-centric B plot coming soon, if not a main story. Let's hope I'm proven right, and they do a good job.

Wednesday, June 10, 2009

Oh, and about those extra initials...

You'll note that for now, "I'm Febrifuge, MS, PA." I can say that much because I got my diploma; the MDs who graduated at that same ceremony are MDs as of now, as well. None of us can actually get a license, hospital privileges, or prescription rights until we pass our respective Board exams.

Actually, there's more to it. The MDs have residency spots lined up, which gives them a sort of blanket license to practice in their home hospitals and any affiliated sites. Me, I need to sit for my national certifying exam (which I'm doing later this month), which when passed lets me apply for all that stuff you need to practice.

At that point, having passed the test, I get to be "PA-C" for certified. That's when the fun begins.

Tuesday, June 09, 2009

Febrifuge, MS, PA

Hey! I graduated!

The law of inverse blogging, or whatever it's called, was in full effect this past couple of months. (Seriously, is there a name for that? The more stuff that happens, the less you feel like/ have time for blogging about it?) Rotation #6 was back home at the very ED where I was a tech, but now I was treating patients and doing the same job as the residents. #7 was an elective in Trauma; I had such fun working my ass off in Michigan that I thought of trauma & critical care as a career option.

Turns out I was a genius for picking this elective, because nothing clears up the rosy glow of a great rotation like doing something similar in a crappier environment. Compared to the group of highly-skilled, generally pretty happy surgeons and kick-ass PAs I'd worked with in Flint, the West Side Chicago crew was overworked, overextended, territorial, and maybe shouldn't have had students around in the first place. It was not awesome, but I learned a ton about the work environment I don't want, and how to recognize it.

Oh. See how much more honest I can be now that I have my diploma?

My final eight weeks was in the suburban ER. I liked the idea of this, because whether it was back home prior to PA school, on my EM rotation, doing surgery in the 'hood, or the Trauma elective, all my ER experience has been in the grim n' gritty urban centers. And the jobs really tend to be in the suburbs.

Again, there's a lot to be gained from seeing things from the other side. I liked the work, and I was pretty good at it. The skills I've developed over this whole thing are the ones that sort of have to come to you organically; one preceptor said I have "street smarts," which I loved to hear. And in the 'burbs, those come in handy, if not very often. Maybe I'll tell you the story about the guy who, no kidding, said "my father is on the board of this hospital." I'll definitely be talking about the TV show that reminds me of.

So I don't know. I love emergency med, and I'd bet I'll wind up there for a long time... but maybe not quite yet. I want to do other things too, and maybe for that all-important First Job After School, I should start in an area where I can do more general, hospital-based work. More on that as we go, too.