Tallochar's blog

Sometimes I like to count how many likes it took before they said “fuck it I gotta follow her,” and it makes me kick my feet in happiness.

One of the main things a resident is expected to do is teach interns and students. And Mohan is interestingly pretty bad at this. I just watched the episode where Santos says one awkward thing to a patient. She’s a new intern and she didn’t handle a patient’s overwhelming emotions perfectly. She wasn’t particularly bad, just not ideal. This isn’t surprising. This is a learned skill for many people.

Mohan takes Santos out of the room and dresses her down her in the middle of the hall. She doesn’t invite a conversation where Santos can reflect and learn. Samira speaks over Santos, shames her, and lectures her. She does the same with Whitaker and the sickle cell patient when she shames him in the middle of the hall rather than encourage him to learn from a common mistake. Both times she’s right in pointing out what her trainee did wrong, but she’s so aggressive and condescending that she’s going to alienate her trainees rather than let them reflect and grow from her feedback. Then she lets Santos take the fall for her mistake with the hyponatremia patient, which is quite a choice for a resident to make.

Langdon wants to keep giving benzos we assume because he knows that what the patient got was actually saline. Putting that horror aside for one second, his suggestion that they repeatedly give benzos and even intubate a patient in status prior to giving an anti-seizure medication is just wildly incorrect management.

Robby lets Langdon get away with continuing this incorrect management but another attending might not have and then the patient what, would never have gotten benzos at all? That’s insane to think about.

Which brings me to how shocking this is on a rewatch. Langdon is taking an action that could have killed or caused serious permanent cognitive impairment to this patient. Who knows how many patients have been harmed. The ED treats a whole lot of alcohol withdrawal which is treated with benzos and is potentially lethal if not treated correctly.

It’s completely understandable that Santos feels like she’s being gaslit when he’s welcomed back warmly. The problem isn’t the substance use disorder. The problem is his utter disregard for taking an action that might have killed patients. Robby too gets a lot of pushback for not welcoming Langdon warmly, but again he knows that Langdon stole drugs and could have harmed patients. And Langdon’s many apologies seem never to wrestle with the real moral failing of his, forever hiding behind addiction to not take responsibility for having possibly done real harm to numerous patients.

There’s no evidence to suggest that Robby is racist, though of course all people of all races often have some internalized stereotypes and biases. But this is a character who canonically has dated two women of color, has a stepson he’s close to who is a Black man, and whose beloved mentor was a Black man. Robby is not positioned in the narrative as the epitome of racism in the Pitt, even if it is reasonable to note that subconscious biases may impact the actions of all characters and people.

Unconsciously or consciously I do think the antisemitic discourse that has taken over tumblr and the left plays into this view of Robby. Antisemitism is a prejudge that is extremely flexible and at the crux of it is viewing Jews as the antithesis of something good or righteous. Jews become a convenient scapegoat, a way to externally displace what is hated within a society, a group to blame for problems rather than work to fix those problems. Right now when the left has come to definite whiteness as the root of all evil, Jews have become viewed as the most white, the embodiment of all the sins of white people and white societies, despite Jews historically (and still in many contexts) being seen as a racialized minority.

Realistically Al-Hashimi probably does need to take time off until her seizures are better controlled. Not that she permanently can’t work in the ED, but she probably can’t do that safely now. Or at least she can’t safely do procedures or work in traumas. Because having an absence seizure in the middle of a procedure could result in a patient dying.

The fact that she’s so surprised she’s having seizures at work that she urgently calls her neurologist tells me her seizures have been well controlled before. So it’s unfortunately a time when she needs to have her medication adjusted and wait for a period of seizure free time before returning to doing any procedures.

I love what it tells us about her character that she discloses this to Robby. I imagine it’s because she knows she can’t be working in this capacity right now and needs someone to hold her accountable for that. For reference after a seizure in most states you legally cannot drive until you are seizure free for a period of time, usually around six months. What she does for work has a similar level of risk to those around her as if she had a seizure while driving.

I’m not sure if she disclosed her seizure disorder when applying for a medical license. I’d guess not. There’s just a question that asks if you are physically and mentally able to practice medicine. Which if her seizures were well controlled then, she would have been. So unless she self-disclosed there would be no regulation or oversight there. And by asking Robby his opinion, she’s taking her own desire to keep working out of the picture and getting an objective opinion knowing full well what he will say.

She just spent the day doing something risky and getting away with it. It’s her first day at work and an hour or two in she has a seizure, presumably for the first time in a long time. And then she has two more. But no one dies or is harmed and she gets through the day and does good work. And there’s the risk to try to get away with it again and just not say anything. Because it was ok today so it will be ok tomorrow right? She can just keep going.

I love what it says about her as a person that she stops herself from doing that by asking Robby. The desire to keep working and not let this get in the way of her career must be there, but she discloses this to Robby knowing he can’t possibly tell her it’s ok to keep working like this. She can do administrative work. She can see non-trauma patients and do medicine without procedures right now. But she can’t keep doing what she is doing until her seizures are well controlled again.

I love that she knows this and also knows that if she doesn’t tell someone she might lie to herself and keep working even though she knows it is a safety risk. It’s an important level of insight. She does what Robby doesn’t. She asks for help. She asks him to think about her situation without the bias of what she wants for herself. She asks him to see that she isn’t safe right now. She’s struggling to accept it, knows on some level. But her judgment is clouded by what she wants for herself. And she’s brave enough to stop and ask someone to check her before she does hurt a patient.

It’s not ableist to suggest that someone who cannot currently safely practice one aspect of her job should not practice that aspect of her job for a period of time. A very reasonable thing here is a medical accommodation. She could continue her administrative work, her clinical informatics work, and could also work clinically in certain capacities. She is able to see patients who do not need procedures, and there are plenty of such patients in the ED. This would mean she’s always scheduled when another attending is on so that she is not seeing traumas for example or other patients who might require procedures where her having a seizure during their care would be dangerous.

I don’t think that what we want as a society is to ask people to work in capacities that they are unable to work safely. What we want is for people with disabilities and chronic medical conditions to have their jobs protected. This means having the right to take off for a period of time when medically necessary without the fear of losing their job. It also means working with accommodations when medically necessary. There are laws in the US that protect people from being fired if they need to take off or work with modifications due to a medical condition. As a primary care doctor I fill out hundreds of forms for people for this exact reason. This is an important right that people have.

It isn’t helpful to suggest that people need to work when it is potentially harmful to their own health or in this case potentially harmful to their patients’ health. If what you want is for people with chronic medical conditions to be able to continue to work in medicine, then that means they are given accommodations when needed. There isn’t something discriminatory or shameful about suggesting that Baran needs a period of time without seizures before she can work without accommodations. That is a medical necessity for her. She likely can return to working without restrictions in the future as it seems her seizure disorder has previously been well controlled. But what’s key is that she can work in a different capacity than the one she was hired for without retribution from her employer and without fear for losing her job or not getting paid. That’s what protection for people with disabilities in the workplace means.

First some context about her seizure disorder and its treatment.

In 2x15 Baran mentions having temporal lobe epilepsy. She mentions having drug-resistant epilepsy (meaning continued seizures despite trials of two appropriate anti-seizure medications at appropriate doses). And she mentions that twelve years ago she had laser ablation and that her seizure focus was in her left temporal lobe.

First a mention of her having had viral meningitis at five and that her illness was severe and prolonged. This means that she likely had a fairly traumatic experience at that age involving an LP and an ICU admission. ICU means being sedated and restrained for safety very frequently. Studies show that about twenty percent of people who survive ICU admissions have PTSD following that event.

As far as what her seizures are like, we know she has focal seizures, meaning originating in one part of the brain. We see her have two focal seizures with impaired awareness which is exactly what it sounds like, a seizure beginning in one part of the brain causing the person to be unaware of their surroundings. Typically these last 30 seconds to two minutes. What they look like depends on the part of the brain they occur in and what we see from her is common for a temporal lobe seizure - behavioral arrest for about 30 seconds without awareness and maybe with some eye blinking.

Context from an interview with Moafi was that the scene before Baran calls her neurologist she had a focal aware seizure or aura. This is a seizure where someone retains awareness. For temporal lobe epilepsy this aura (which often proceeds having a focal unaware seizure) often takes the form of a feeling of deja vu, a rising feeling in the stomach, olfactory or gustatory hallucinations, though these are many other manifestations.

The third type of focal seizure is a focal seizure that then generalizes to bilateral tonic-clonic (tonic-clonic seizures being the type you commonly see depicted in media with stiffening of the body then rhythmic shaking and a prolonged period of confusion after). This is not something we see but is something that it would be reasonable to imagine might have occurred at some point in her history when her epilepsy was less well controlled.

A note on drug-resistant epilepsy. For people who have failed two anti-seizure medications the chance of having seizure freedom with a medication change is only about five percent. So it’s very telling that Baran spent decades trialing and failing many medications. That’s a long and frustrating process. And most of these medications have a lot of side effects. People often change medicines due to side effects and often people are accepting the least bad option when it comes to side effects rather than choosing a medication with no side effects.

She mentions her current medication is levetiracetam. This is a medication she might have been changed to prior to getting pregnant as it’s one of the two preferred medications in pregnancy due to its safety for the fetus. It has a lot of potential side effects including a high risk of psychiatric side effects and is not used in patients with concomitant mental health conditions. Commonly this medication can cause dizziness, fatigue, and cognitive impairment (common with most anti-seizure medications and surely something a physician would weigh strongly / worry about when changing medications). Other common side effects with this medication are nausea and loss of appetite.

For people with drug-resistant epilepsy who have a focal lesion amenable to surgery about half of people who have surgery will be seizure free after a year (though some people have later recurrence of seizures, which is what I think we’re meant to assume happened to Baran after ablation). It sounds like she has a seizure focus close to an area of the brain related to speech which made surgery a risky choice. We can think about how for this woman whose career is very dependent on cognitive ability this would be a difficult choice.

What this means is from age five to 28, Baran was having somewhat regular seizures. She says before ablation it was every few months. Likely given the repeated med changes it was much worse when she was younger and the best they got to with meds was reasonably well controlled with seizures every few months. And while that’s infrequent there are still serious limitations to how she would be able to live her life. Think of the safety of things like driving, swimming, running on a treadmill, cooking, if you might have a lapse in consciousness for two minutes. And think of the dangers of having a very young child.

Surgery became fairly standard about twenty years ago. Ablation, the procedure she did have, which is accomplished with a less invasive type of procedure, only about ten years ago. So it sounds like she probably would have had a surgical evaluation as a teen and her parents then Baran herself decided this was too risky. She ultimately decided on an ablation 12 years ago which would have been around the end of med school/ beginning of residency. Interesting to think about this too as a choice that really impacted her career and her choice to pursue an emergency medicine residency.

Thinking about her career timeline:

If she went straight through school without time off:

Graduates college at 22, med school at 26, and residency at 29 or 30 (depending on if she did a three or four year program). This would mean she chose a speciality she couldn’t practice in fully as she was still having active seizures at 26.

Alternately we can shift things to her taking time off between college and med school, graduating at 29, which would have allowed her to have seen that the ablation made her seizure free and then chose emergency medicine as her speciality. This makes more sense to me. Ablation was still a choice with risks but she pursued it possibly in part to allow her to follow a career path in medicine that was important to her.

If she did a three year residency that means she finished at 32 in 2018. MSF typically wants two years of work experience, so she worked somewhere domestically for two years. We know she was in Afghanistan in 2020, so perhaps abroad 2020-2022. She returns to the US at 36, works at the VA for four years, then taken the job at the Pitt.

We know she had a seizure a year ago. We don’t know if she had others between then and the ablation in 2014. And we can probably assume she had a child after returning to the US so her kid would be two or three. That means she’s probably fairly recently divorced.

First I want to set up a framework. Being Ashkenazi Jewish means often being perceived as white and also being part of a racialized minority. What do I mean by racialized minority? That this group is understood in a social context as distinctly immutably other. Remember that racial groups are very much social constructs rather than facts of genetics. If this is hard to grasp, it might help to think about other groups like Latinos or Arabs and how they are viewed in America. A person in these groups might look white but when someone finds out they are part of this group they are understood to be not white. Jews are historically viewed as a racialized other in most places in the world. This is very much true in American history even if we think of Jews here as having been accepted as white. Remember back when businesses had signs that no Black people were allowed, at the same period of time there were signs all over America at those same establishments saying no Jews allowed.

For context of my experience: I’m a Jewish woman with Ashkenazi heritage who looks pretty stereotypically Jewish but doesn’t wear anything that would identify that I’m Jewish. What this means is that if I’m in a place with a large Jewish community I’m typically read as Jewish. If I’m somewhere that people have rarely met Jews before then I’m read as white.

Here are fun things that happen when your patients read you as white:

- you get to listen to them say wildly antisemitic conspiracy theories and assume you agree and want to hear it

- you get to examine your patients and find their neonazi tattoos that they seem entirely unashamed for someone to see

- you get to debate whether to tell patients that you’re Jewish or to lie. For me because I work in an outpatient setting and know my patients for years, at some point when they ask what I’m doing for Easter or Christmas, I often do tell them I’m Jewish. And then unfortunately you get to deal with a myriad of responses ranging from “oh that’s ok dear, I don’t mind,” to a patient of mine who came to their next visit and handed me two typed pages explaining why the Jews faked the Holocaust so they could take over Palestine and how Jews love murdering babies (real experience I had).

-you get to do this same dance with coworkers. You get to have coworkers you considered friends say antisemitic things and feel betrayed.

This is not an experience of privilege. This is an experience of hiding. This is an experience of wondering how many patients who seem perfectly nice actually think vile things about you. It’s an experience of calculating if it’s safe to be open with patients or colleagues.

And over the last few years it’s also the experience of having people devalue the discrimination and pain that the Jewish community is experiencing. For non-Americans, Jews experience close to the greatest number of hate crimes in this country and by far the greatest compared to the size of our population. This is of course a global phenomenon but I know the US statistics and we’re discussing an American context so that’s what I am sharing. Despite this I watched the CEO of the healthcare organization I work for send out an email condemning every other type of racism. She sent an appropriate email after George Floyd was murdered calling out systemic racism. She sent an email calling out racism against Latinos in the wake of everything our government is trying to do. But after Bondi Beach there was an email saying that gun violence was bad and never once mentioning antisemitism. And after October 7th there was silence. Being a Jew at a progressive healthcare organization has meant going from feeling like part of a coalition of people with common purpose to understanding yourself to have become many of your coworkers’ favorite scapegoat for all the evil in the world.

Being Jewish in America right now, as in most of the diaspora, is to feel profoundly isolated. To calculate when it is safe to disclose being Jewish to people who read you as white (or for that matter who read you as solely Black or Asian as is the experience of two of my friends who are biracial and so are never read as Jewish).

I think when people watch the Pitt they think about how being a woman in medicine or a Black person in medicine shapes that experience, how it’s complicated to have power over patients as a physician but also to have them demean you with sexist comments or assumptions that you’re a nurse or a CNA.

But I’m not sure viewers think about what it’s like to be Jewish in medicine. How you listen to patients repeatedly say antisemitic things and assume you agree. How sometimes they do know you’re Jewish and say antisemitic things to your face. How you calculate constantly how to respond when patients start talking about Jesus and ask if you believe (which they do all the time because this is America and people are so upfront about their Christianity). It’s tiring and othering and the experience of patients and coworkers being bigoted against you contributes to burnout.

Intellectual property laws used to mean something when it targeted the consumer.

On what the male loneliness epidemic is really about. Given actual alternatives, women are opting tf OUT of "traditional roles".