Eve of

War Christmas

She was born this morning around five.  I walked in to meet her and examine her.  It was as if nerve gas had gone off in the room.  Three people, completely unconscious, barely arousable to a shouted “HOLA SOY DOCTORA BISON POR FAVOR PUEDO EXAMINAR A SU BEBE?”

She has curly black hair and looks like what angels might when they’re born.  Or when they spring fully formed from their father’s foreheads.  Or however angels regenerate.

She has a stork bite mark on her forehead.

She barely rouses when I uncover her to check her belly and hips.  Together we wrap her again and she goes back to sleep.

Oh, yeah, my dad is with me today.

He came to follow me on call.  We round together and discuss the cases.  I push aside the nagging worry of appearing incompetent in front of my father, and it’s really fun.  It’s also lovely to talk through the cases with someone else again.

On the way home for lunch we talk about illegal immigration.  We’re of the same mind on this one, I think.  Like, seriously, America, can’t we move on?  These are people.  Most of whom contribute to society.  Most of whom live in what used to be Mexico.  All of whom just want a better life for their children.  Just like me.  Just like you.

Mom’s not convinced.  We talk about their difficulties of the last four months. 

At home we make enchiladas.  My 22-year-old brother wants us to help him decide whether he’s a republican or a democrat.

Dad:  “How do you feel about gun control?”

Buddy:  “There should be less.”

Dad:  “Okay, then you’re a republican.”

Dad:  “How do you feel about women’s right to choose?”

Buddy: “Women shouldn’t have any rights. (ha ha snicker snicker.)”

Dad:  “Then you’re republican.”

Mom (staunch republican): “That’s not a republican value!”

Me:  “Right. He’s an Iranian.”

Later, doing dishes, Mom tells me how upset she got with my father a few months ago, how she almost thought of leaving, for good.

Really?  Mom?  I thought I was the only one who had those thoughts. Months ago now, but still. 

Is there hope for any of us?

I wrap gifts for my kids and can’t help thinking about all the overflowing heaps in dumpsters and landfills and fragments of plastic and worse that all these toys will be in just a few years.  And how so many other mothers’ children lie awake tonight, hungry, without a roof over their heads.  While my children fight over their mountains of belongings. 

But these plastic playthings will outlive any of us.  And since we’ll all die soon, does any of it matter?  The toys, the trash, the hunger? 

God, these are not very Christmassy thoughts.

My heart feels like a noiseless patient spider, sending forth filament after filament until the ductile anchor hold.  No, wait.   That’s Walt Whitman.  Actually maybe it’s just a vagrant, tired, unsettled.  Ideas and yearnings burgeoning, just about to be born, if they could only be organized.  Searching still, nightly, looking for a home.  Or maybe just a hotel room.

The family, all of them, bundle up to walk to the downtown festival of lights.  I put on my coat but drive to another home of sorts, the place where life so often begins and ends. 

Three ambulances stand between me and the back door.

Baby Guadalupe was not in a hurry.  We sat together for more than an hour before she decided to meet us.  But she was beautiful, quiet when she came, eyes wide open.  A family of 20 descended immediately upon her and her mother as I departed.  “Feliz Navidad, y que Dios le bendiga.”

So what can we offer this new innocent wonder?  What do we have to give this life?  Just fragments and plastic, war abroad and domestic disputes?  Parents too tired, from mundane struggles, to make this world a better place?  Minds full and spinning and with television and coffee and bills and weekday and weekend.  Feuding, fighting, acquiescing, quietly stewing.  Rotting, decomposing, dying.

No.  It has to be better than this.  We have to make it so. 

The cold is bitter, dark as it greets me.  My car and I speed through the night.  As I pull into the driveway I see a dawning glow. 

GB made me my own set of lights.  The luminaria glow alongside the path to our door.  I feel the heaviness lifting.

Peace. On. Earth.

Monster Hospital

Yesterday I woke up and I didn’t like my job anymore.  I had a bad feeling in my stomach as I backed out of the driveway.   Then I made an attempt to identify the factors which led to this feeling.  I outlined the following:

1)   It is 6:30am

2)   I was hanging out with the kids all weekend, leading to:

a.     Utter exhaustion

b.     Wanting to hang out with those guys even more

3)   I’m afraid of the hospital

Then I had the following self-dialogue.

“Um, you are 30 years old.  You are a doctor.  Why are you afraid of the hospital?”

“I’m a crappy doctor.”

“Why do you think you’re a crappy doctor?”

“Because that one lady was mean to me.”

“Because a lady was mean to you.  What lady?”

“Let me fill my self in.  Last time I was on call there was a lac I thought was a third degree and I’ve never repaired one and I didn’t want the patient to be incontinent for the rest of her life, so I called Her.”

“You called the patient?”

“Uh, no.  I called Her.  The OB on call.”

“Ah.  The one who told you you couldn’t do a pelvic exam.”

“Yes Her.  And She told me if I can’t repair my lacs maybe I shouldn’t deliver babies.”

“And you believed Her?”

“Yes.”

Yes, yes I did.  This is the thing about me.  I believe what other people say.  I take it seriously.  And so probably I shouldn’t be delivering babies.

That makes me sad.  Also it makes me not want to go to the hospital.  Because what else should I be able to do that I can’t?  What else should I know that I don’t? 

I’ve said I believe in family medicine, more than I believe in myself.  I believe that competence can be something other than knowing everything, being able to do it all.   Competence is listening, understanding, explaining.  Taking care of most things, and perhaps most of all, knowing when to ask for help.  Yeah, that’s what I believe.

Except on the days I don’t.

All I really want is what’s best for the patient.  Almost always I believe that they should all have family doctors who care and have a relationship with them and only very rarely need to ask for help.  Almost always I believe this will provide excellent care with better outcomes at a lower cost.

Except when I don’t. 

And when I figure, maybe I should just stay home with the kids.

I feel defeated.  And now I’m already halfway to the hospital.  I’m lame.  I don’t want to go but I’m in too deep to get out of this, so I sheepishly keep showing up to work.

But I also feel a little bit angry.

Who is She, to take away my fire?  Who is She to turn someone like me into a defeated apathetic heap?  I mean, at least I’m nice.  Also, I speak Spanish.  Also, I’m conscientious.  I’m reasonably intelligent. 

And I care, damn it.  I care about these people. 

Hundreds of folks have invested in my training.  I’ve invested years of my life.  I’ve shown up at 4am for Surgery rotation, stayed ‘til 9pm after clinic.  I’ve spent countless hours away from my kids, so many nights away from my bed.  I’ve studied about and rounded on and written notes on and talked with and sat with and broken bad news to and operated on and bargained with and delivered babies to thousands of patients all day and all night and all day again for seven years.  All because I believe.  I believe I might one day make a difference for my patients.  Who is She to stand between me and my patients?  Because that’s what She’s doing.

Because I’m letting Her.

The hospital looms like an ungainly monster.  It’s snowing hard.  I park next to the helipad and sit in the drivers seat.  The temperature plummets as I turn off the car, step outside the car. 

There’s still a little fire in my belly.  I hardly notice the chill as I run for the Emergency Room door.

The Other Shoe Dropping

Wait for it...

When I saw the schedule at first, I was glad she was coming in.  She’d be the last patient of the day.  We could figure out how her blood pressure had been, since somehow she hadn’t followed-up since a month ago when she’d been at 200/100.  We gave some clonidine in the office, then I started some meds for home. She was supposed to see me the next week but didn’t.  Then she had a stroke.

What?  Holy f*cking shit.  She had a stroke.  The scheduler wrote that in with a couple exclamation points so we would know it was important.  “Here for f/u HTN: Pt had a stroke!!” She is 49.  What the hell just happened to this 49-year-old?  How did I let this happen? 

We have a paper charting system.  We have a completely incomprehensible scheduling system that somehow involves a computer but which I have no access to.  If someone cancels an appointment no one tells me.  These are excuses, I know.  I should have put her on some kind of list so I’d remember to call her if I didn’t see her the next week.

A lot of times I’ve thought about when the other shoe might drop.  When I will blow it big-time and miss something or make a fatal error.  Back when I was a resident, hoping to get into a car accident each morning as I drove to work so I could get some rest in a hospital bed, losing my job didn’t sound so bad.  I’m sure I could find something else to do with my time.  Like, I don’t know, hang out with my kids.

Now I’m more ambivalent.  I think I actually like this crazy job and would be a little sad to let it go.  But that’s all a moot point next to the utterly sickening, kick-you-in-the-gut feeling that you’ve let someone down in a big way.  In a life-and-limb- altering way.

There were still 7 other people to talk to about their various manifestations of candidiasis before I saw her.  Obviously candida matters but it’s hard to really focus on it when obtrusive thoughts keep leaping into your brain.  “Do you have itching?” I just nearly killed someone.  “Yes.” I am going to lose my job. “I think it would be helpful to do a pelvic exam.” She can’t walk because of me.

When I walked into the room she smiled at me meekly.  Her kids were there with her.  “I am so sorry this happened to you.”  What else do you say?  Turns out she’d checked her blood pressure daily after I saw her last.  It was 130/70 or thereabouts each time.  She didn’t see the cardiologist I referred her to because her paperwork didn’t go through.  She forgot to come back to see me.  Then she had a stroke.  I asked her about drug use, about symptoms of pheochromocytoma.  No, and no.  And her blood pressure was normal the morning of the stroke.

What the hell?  This doesn’t make any sense.  Why?

I sent her home with a giant jug to collect her urine for 24 hours.  When she left I finally got my hands on the discharge summary.  Utox on admission positive for cocaine.  She admitted regular use to the neurosurgeon.  So now I’m vindicated by blow.  But she refuses to talk to me about it. 

So I’ve failed her, but in a different way than I thought.  I failed to gain her trust.  Or maybe to kick her kids out of the room so she’d give me a straight answer.  I get to keep my job.   Does she get back her left arm?

I guess we’ll have to wait and see.

You Think

This Budd's for You

Today was a late day. I did not get all my dictations done in time because I was Budd-Chiari-ing.

Budd-Chiari-ing is when your last patient in the morning comes to see you and he is young and without any medical conditions except he spontaneously developed Budd-Chiari syndrome for no reason 2 weeks ago. And they discharged him from the hospital despite ongoing fevers and no diagnosis. And now in your office he has a temperature to 103 in front of you and feels sick. But his blood cultures were negative before.

And you look on Up-to-Date for all the Causes of Portal Vein Thrombosis and check them off one by one as you determine they are unlikely, looking in the mouth for ulcers (Bechet’s disease) and palpating the testes for tumors (hypercoagulable state?) And then you look up Fever of Unknown Origin.

And then you call a bunch of specialists and stay through lunch hoping the Infectious Disease guy will call you back and the GI doctor does but he tells you a bunch of tangential anecdotes and the Heme-Onc guy doesn’t think it’s a Heme-Onc issue but gives you advice anyway that is in conflict with the GI doctor’s advice.

And it’s time to see more patients so you order some labs and arrange to speak with them by phone in the next 48 hours. And you call the ID doctor again and he ignores you.

And you think and you think and you think.

And you see some more patients.

And finally you talk to the Dinosaur. He’s got a few minutes. You sit together and look everything over one more time.

“I’d order an RF, CRP, ESR, CBC, and repeat ANA, as well as repeat blood cultures.”

Yep, that’s what I had already ordered.

“Sorry I can’t help more than that though. I really don’t know what’s going on.”

Somehow, this was reassuring. I was on the right track. And a very smart someone had no better idea what was going on than I. It shouldn’t be reassuring, but it was.

After Budd-Chiari-ing all day, one still has to complete one’s notes. So that’s what I did. I was the last one leaving the clinic. Outside, snow covered everything. It crunched underneath my feet.

Alive

Not Reading Journal Watch

I am not even going to tell you how many unread Journal Watch emails I have in my inbox. I really need to read them.

Instead I have been fashioning splints today. Today was Carpal Tunnel Day at my clinic. No folks with Carpal Tunnel Syndrome had any insurance so I made some gigantic bilateral plaster of paris splints with ace wraps for these ladies. I joked to the one lady’s son that we’d make a piñata next. You shouldn’t joke about these things with 5-year-olds.

It was a very hands-on day, in a way some days aren’t. Holding the splint in place, making small talk for 5 minutes. Sitting between the stirrups, talking a woman through an IUD insertion. Chatting to the ultrasound image of a baby’s face, just 3 weeks before she’ll be born. Measuring a penis for a concerned mother. Fundoscopic exam of a 6-year-old. Feeling the rough boundaries of a weird-looking rash. Didn’t read much at all today.

Another weird thing happened. Like 3 other providers asked me my opinion. The OB/GYN asked me a pre-operative question about hypertension and showed me an EKG. The midwife had me come in to check on a kid’s hernia. The PA with 30 years experience that I curbside all the time ran some ideas by me on a sick guy who won’t go to the hospital.

What is this? Do these people have any idea who they’re talking to? I still have to look up how to do certain joint injections. I STILL don’t know how to spell amitriptyline. Yesterday I sent someone home on accident with a recorded heart rate of 35, according to the medical assistant who took the vitals.

Yes, he was still alive. No, I didn’t notice the vitals before he left, because he was totally fine. Yes I noticed it while dictating. Yes I fell off my chair.

We called him yesterday evening and talked him through checking his own pulse. In 30 seconds he counted 13. “I feel great, doc! I don’t know what the big deal is. I’ll come in tomorrow, ok? I don’t have a ride right now.”

And I didn’t send the ambulance to his house because there was no way his heart rate was 26. But my heart rate was 120’s with frequent accels for the next 18 hours.

He sauntered in over lunch break today. I put him in a room myself and put my hands on his right radial artery. Pulse 88. I placed the blood pressure cuff over his upper arm, and inflated it manually. 140/80.

Still alive.

Impostor

For Planck, and the Physics-ian

I love it when I have a patient who talks to me about Physics. “Quantum physics, now that’s really just another explanation for the soul,” he added.  I nodded my head.   “I never felt like I got enough Physics in College,” I lamented to him.  “Me neither,” he replied, and went on to outline some recent findings about Neutrinos that travel faster than the speed of light.  My curiosity, long suppressed by trying to cram More Facts into my head, awakened.  I remembered the wide-eyed wonder of the world split open, looked at through a hundred different glasses, tiny colored pieces of light falling together into a giant Mandelbrot set.  Philosophy, poetry, Chemistry.  Always feeling the truth is out there for the honest seekers.  Physics.  I love it when patients talk to me about Physics.

Except that I don’t.  Because there’s someone in front of me who might be as smart as me.  He likely has the internet at his house.  He knows about his meds and doses.  He tells me he wants a higher dose of testosterone.  I assume they make it in a higher dose, but I don’t know.  I’ve never prescribed that medication before.

There are a lot of things I don’t know, actually.  Turns out I can’t ever spell amitriptyline without looking it up.   I’m pretty honest about what I know and what I don’t know, to the extent I can still manage to keep my patient’s confidence and my colleague’s respect.  It’s such a balancing act, though. 

And some day soon they’re all going to find out that I had to look up cervical radiculopathy treatment.

In medical school I complained to my classmates when a test was difficult, expecting them to commiserate.  They didn’t.   I felt stupid.  Turned out I did better than most of them. But I didn’t know about the game we were all playing, called “Act like you know what the f*ck you’re doing.”  If you don’t know the answer, don’t tell people that, of course.  What was I thinking?

So I learned.  And when I was an intern it was approximately the opposite.  I held on to my doubts, and folks told me I was doing great.  I smiled and nodded, and panicked on the inside.  One day soon they would realize I don’t know anything and fire me.  Then I’d be done.

But I wasn’t done yet.  I finished the whole darned residency.  And here I am.

Today I printed off the ASCCP guidelines.  Again.  Because not only do I not remember them, also I lost the copies I had.

Also, which one is Diovan?  And what’s the highest dose of that?  And how do I know if someone has Sjogren’s syndrome?  And why does this 15 day old kid have conjunctivitis?  And what do I do about galactorrhea?  And is it ok to take Trazodone and amitriptyline and gabapentin together?  And OverActive Bladder.  Is that even a thing?  (Still not convinced).  By the end of the day I had 6 AAFP articles pulled up and 2 up-to-date articles all on my desktop. 

Soon everyone will know what a fake I am.  They’ll figure out I really don’t know much of anything.  Really I’m just a dork with a 12-year-old’s sense of humor who guessed enough questions right on enough tests and showed up to work enough times to pass just under the radar.  Am I even sure I’m not still in high school?

This is why I hate the sophisticated patient.  He’ll only unravel this web of lies quicker than the others.  Then I’ll have to get a job faxing things.  And I still have loans, people.

This is called “impostor syndrome.”  I thought I was the only one who had it.  Nah, turns out.  Some of the smartest doctors I know complain about it on Facebook.

If it says it on Facebook, it must be true.  There are a lot of impostors out there.

Mi Vida

Daughter

She’s 16.  Since the process takes 9 months, she was 15 when it all started.  And now she’s going to have a baby.

She’s brave.  Braver than I was then.  Braver than I am now.  15 for me was about running wild through the woods and creeks and camping with friends.  It was about bowling.  Clandestine driving on county roads.  Algebra II.  Big dreams.  The world at your doorstep.

Fighting with my mother, or “becoming independent.”

Because, for some reason I’ve never understood, I was lucky.  I wasn’t raped.

Her mother sits now, at her side.  English is her second language.  She smiles at me as I describe why we need to keep her daughter overnight for extended monitoring, even though she’s very early in labor.  She has another contraction.  Her face barely registers the pain.

Is it because this pain, what many of us consider the most intense experience of our lives, pales in comparison to what she’s already seen?

Mother gets up from the chair to hold her hand.

Two hours earlier, Mother had called me to ask when she should bring her daughter in.  Contractions had been every 5 minutes for a while.  We talked.  I asked some questions, gave some advice.  Here’s what I didn’t ask:  “Do you have a ride to the hospital?”

The nurses learned she didn’t.  They arranged a taxi voucher.

Tonight there turns out to be a lot of questions I should have asked.  A 20-year-old just had her second child. I had seen her in the office a week ago, and asked if she was safe in her relationships.   I asked if the father would be involved.  Yes, and he also lived with her.  I asked, as politely as I could, why she didn’t come earlier to prenatal care than 37 weeks.  What I didn’t ask, in my condensed 11-prenatal-visits-in-one, was “Do you plan to keep this baby? Or will you be adopting the baby to a relative who lives with you and the father of the baby, from whom you are officially separated?”

Sometimes you just don’t think to ask these things.  If you did, you’d open a door into someone’s world that they maybe don’t even want you to know.  Some patients want to hide their pain from the doctor.  But you cannot hide it from your mother.

My aunt posted a picture on Facebook tonight.  It is my grandmother, whom I never met.  She is around 2, holding someone’s hand, clutching a stuffed toy.

She looks EXACTLY like my daughter.  Down to the curls, dark blond.  The small, rosebud lips.  The round, serious face breaking occasionally into a silly, ecstatic laugh.  My daughter carts around a similar toy, called “Creature.”

The other baby, my grandmother, lost her ability to move from the neck down at the age of 25.  She died of pneumonia, after 8 years raising her daughters from a hospital bed, at 33.

Suddenly my eyes burn.  My own girl is tucked into bed, sleeping quietly in that beautiful way she does.  And I brought her into this world, on a day not unlike today, knowing how much it could hurt her.  Her life is a piece of my heart, walking freely through the world.

I saw a flash of myself in the 16-year-old.  Then in the mother’s face, bent low over her daughter, kissing her gently at the crest of the contraction.  The girl goes back to sleep between the pains.

I saw myself older, then, sitting next to a hospital bed, next to a handicapped child, with children of her own.

The phone pulled me out of my reverie.  A different woman’s baby was about to make her debut.  No pants could be found in my size.  The nurses said the baby was in a hurry.  The only options were 2XL. I briefly considered delivering the baby without pants on.  How much worse could it be than delivering one without gloves on?  I’ve done that.

Drawstrings are a nice invention, though.  I rushed into the room and caught the child, and handed her to her mother.

“Ah!”  She cooed, like many of my Latina patients do.  “Mi Amor!  Mi vida!” 

I delivered the placenta.  No one ever says these things about the placenta.

Mother went on.  “Mi amorcita!  Ay, bebe!  Ay, mi vida!”

Yes.  My thoughts exactly.  My daughter.  My beautiful.  My life.

Dictator

I hate dictating. It’s like when you use the toilet at the airport that flushes automatically and you’re pretty sure there’s actually a little camera sitting behind that transparent window with the red light, and a little man in some other country where labor is cheaper than here, remotely flushing the toilet when he sees you’re done. I don’t care how many thousands of miles away that person is, I don’t want him watching. I mean, I can flush the toilet myself. Been doing it since I was two.

And when you dictate, someone gets to hear you chew gum, google, and say things like:

“This is a …… 48 year old….. no, 47 year old man who presents today complaining of pain in his left ankle for 5 days, preceded by being bit by a wolf. No, that’s not right….” Shuffle papers… “A meerkat. Being bit by a meerkat. Oh, can you go back up to the top and add 48 year old man with poorly-controlled diabetes. 47 year old. 47 year old.” Long. Awkward. Pause.

“He has noted increasing redness in his left lateral ankle since that time, and an enlarging area of black skin with a charred appearance.

“He has not a fever. Shit. Did I ask him about a fever? Crap. Don’t type ‘shit.’ F*ck.”

*REWIND* “since that time,*chew chew* and an, um, enlarging area of black skin…”

*STOP * LONG PAUSE. Shuffle papers. “With an appearance ‘like it is dead.’ He reports no fever, only feeling cold once at 2am-"

PHONE RINGS

“When are you coming home? We miss you!” (GB and associates)

“When you stop calling me. No! Crap! Don’t type that.” *REWIND* *STOP*

“Ok in a few minutes I promise.”

Right.

Leaving the Room

Sure enough.  There was a lump in his throat.  We had talked about it, and I was already worried he might have an abscess.  Of course, maybe he just had a uvula. It’s amazing what folks will find in their throats when they are looking for the first time.

I got out the light and I looked.   It wasn’t his tonsils, or the spot where the tonsils would be if he had any.  Instead it was behind the base of the tongue, pinkish, and floppy.  “I have no idea what that is,” I said, using the following words:  “Well, sure enough, you have a lump.  You know, it’s hard to see it well and so it’s hard to know exactly what it is.  Actually it could be lots of things like an abscess or some other kind of swelling.  And there are lots of ways to look at it.  Like I could refer you to a specialist, or we could do a CT scan, or someone can look with a camera.” 

“Sure,” the 20-year-old looked at me with wide eyes.

“And we’ll have to figure out how to do that, since you don’t have insurance.”

“Uh-huh,” he looked worried. 

“Let me go talk to some folks about that,”  I said.  Then I left the room. 

Leaving the room is one thing I really miss about being a resident.  There’s so much pressure in the room, to know the dose of everything, to be confident in your assessment, to draw detailed anatomical diagrams of disease processes.  Sometimes you just want to leave to take a breath, to think.  To ask someone else what they think. 

Now, I do not “look like a doctor.”  You might not pick me out of a lineup.  I’m not a tall, grey-haired man.  Nor do I always “look old enough to be a doctor.”  Depending on whether or not the Beastie is screaming for milk at night or T.P. has croup, or if GB forgets to get into bed before he is somnambulant and I have to wake up at 2:30am and drag him off the hardwood floor into the bedroom, the age I appear to be might vary by 10 years the next morning.  If I’m feeling well-rested and refreshed, chances are my patients will politely ask more than once if I am actually a doctor or maybe just got lost on the way to P.E. class.  If, on the other hand I’ve aged overnight from a mere 90 minutes of interrupted half-sleep followed by checking on the respiratory status of 2 or more of my family members, funny thing, no one asks me my age.

I’m always conscious of how credible I might appear, though.  And every time I think about coloring the 15 or so grey hairs on my right hairline, I think again.  I’m going to need all the credibility I can get.

So when I show up to work looking like a barista AND I need to ask someone else for help, it probably undermines my credibility as a doctor.   But what’s best for the patient always comes first.  So I left the room.  And I found the Dinosaur. 

He was busy, “but I’m always busy.”  He shuffled with me back to the patient’s room.  He walked in and greeted the patient by name.  Wait, I hadn’t told him the patient’s name.   “I know this guy.  I’ve known his family for years.”  He got out the light and looked into his throat. 

“You’ve had your tonsils out of course, so they would be inflamed but there’s nothing there.  That swelling at the base of your tongue is probably a lingual tonsil.  It will get better.  No abscess there.”  He smiled at me.

“Thank you,” I said, as he left the room. 

“Anytime.”

“Well, so I guess that’s it.  Want to come back the next time I’m here and we’ll make sure it’s getting better?”

“OK,”  he smiled, fair game.

I wrote out his slip.

“You know, I think the Dinosaur delivered me,” he said as we walked out together.

See, this is why I want to be a family doctor.  Someday, maybe I’ll get it together enough to know a family like this.  Someday I’ll have seen enough tongues and throats and rashes and variances that I can look and reassure and then ask about Aunt Matilda.  I’ll see the kids I deliver grow up to have kids of their own.  Then one day I’ll need to go to the doctor for some problems of my own.

And if she needs to leave the room for a minute in the middle of it all, I’ll let her.  I’ll probably be relieved.

Fire?

Strategic history and physical today of a 4 year old hyperactive child with headaches:  

He begins by shouting into the intercom phone in the room.  We complete our HPI talking on imaginary phones.  Observing him slide in and out the pap stirrups = motor exam.  He dives into the biohazard bin.  I ask him to please not dive into the biohazard bin.   Gross motor+language comprehension.  He discovers the pap light.  No photophobia, it seems.  Pupils are equally reactive to light.   

He shines the light on the wall. 

“Oh no, guys, it’s a fire!”  He yells.

“Really?”

“Yeah! Get in the car!”

I wheel my stool around the room.  He drives the procedures cart.

“Grab the hose!” I shout.

He grabs my pen.

“Fire!!” He yells.

“Put it out!” We both spray the wall with the hose.  We have to hold on tight because it is one of those huge ones on fire trucks, you know. 

The kick back causes the procedures cart to crash into the wall.

My medical assistant bursts through the door.

“Are you guys alright in here?”

“Um, yeah,” I say.

“Guys!  There’s an alien! WATCHOUT!”  He bolts from the room.

I guess we’re done?

To Understand

yellow eyes

"I think he smells a bit like alcohol, but maybe it's just me," Sonrisa said as she handed me the chart. "Are you drinking on the job again?" I asked her.

I went into the room and met the man, who was there with his daughter. He immediately wanted to talk about his memory difficulties. He just couldn't understand why he can't remember anything anymore. "Is there a test we can take for that?"

Ostensibly he was there for a pre-operative physical for an orthopedic surgery. He's had several before, no complications. It’s just that he keeps falling, or crashing, or getting in car wrecks.

I looked over his labs. Bili climbing, now at 4.3. INR 1.4. Platelets 78. Albumin 2.7. Ammonia 83. He's on lactulose.

The operation still hasn't been scheduled. "They said I need to see you first."

He's had 2 GI bleeds before. One was sobering enough he quit drinking for awhile. But it didn't last. Currently he has "cut back a lot," maybe drinking a 6-pack of beer a day.

I wouldn't operate on him either.

"So what do we have to do to get the numbers better?"

"Well, I have good news and bad news. The good news is we can get you better for the surgery. The bad news is it's entirely up to you. You have to stop drinking. Completely."

Tears came into his eyes. Which are yellow. And he hadn't noticed they were yellow before (his daughter had.)

And then we talked for a while about how he could do that. And he decided to go to the hospital.

45 minutes, a perfunctory review of labs, and then I told the patient there was nothing I could do. "Patient, heal thyself." And he has to stop the one security, the one constant in his life. And that's just the way it is.

"You seem like quite a lady," he said as he left. Not sure what he meant by that. I just gave him pretty bad news. This is one situation where I really can't do anything at all. Except listen. And tell him his health is in his hands alone.

What is this force that so destroys the mind, body, and soul? And what is this pain that is so great that he must pour himself full of anesthetic each night? We see it every day. We blame the man for choosing this way of life. And then we move on.

But I want to understand. I want a window into this self-destruction. So many times I’ve wordlessly pleaded with patients to give me some kind of clue. Why does he do it? Because if either one of us knows, then maybe we'll find the key. So the few years left can be spent with family, happier, healthier. I looked him in his yellow eyes. He doesn't want to die yet.

2am

What It's Like

If you can ever help it, don't get sick at night.

People get sick at all times of day or night.  Babies like to be born at night.  This is either because of the lunar cycle or because they like the infomercials their parents are watching in the labor room.

In the middle of the night, brains, even doctor's brains, don't work like they should.  Or maybe they do, it's just that they should be dreaming instead of trying to figure out if a patient's fetal heart tracing is going south.  Or if it's okay to dissolve nitrofurantoin in peach juice. 

When babies are about to be born, my brain becomes aware of the phone ringing, a special ring I chose just for work.  I believe it is called "night of the living dead."  My brain "wakes up."  This means I get to stop dreaming about taking care of patients (having nightmares about codes) and actually take care of patients.  My body finds keys, stumbles over dogs, and climbs into the car.  I drive down empty streets, peering out a tiny clear spot in the frost I forgot to scrape off the windshield.  There is one hospital in town, which was excellent planning on the city's part.  That way I won't show up and deliver the wrong baby at the wrong hospital.  At least I can get one thing right tonight.

It's cold outside the hospital, and the badge system isn't really designed to allow you in the building, just mainly to trap people in the stairwell.  Why is the light flashing red?  Ah.  Wrong badge.  Somehow I make it in and find the call room.  Automatically I enter the door code I used for three years in residency.  Astonishingly it doesn't work.  Then I remember where I am and finally bust through the door. 

I wash my hands in the sink.  The automatic towel dispenser fires next to my ear and I jump a couple of vertical feet.  I look around the counter.  There is a bottle of rice vinegar and a jar of Jif.  This reminds me I'm thirsty.  There are no cups.  I drink tap water out of a giant square tupperware container.

And then I go take care of patients.

The only thing worse than my brain at 2am is the brain of someone with less experience, who is even more tired than I am, from being up without sleep every fourth night.  Like the brains of, for example, all the interns out there tonight, running all the major hospitals in the country.  Once, when that was me, I saw a bear in the hallway.

Dear God, help us.  What is wrong with this system?

Friday

Wine Pairings

Sometimes at the end of a work day, you look around you and say, “What the hell just happened?” Usually this is a Friday evening.

Fridays are awesome. It’s like the last day of a Storewide Clearance Going Out of Business Sale!!! Folks want to get it while the getting’s good. The afternoon gets exponentially more exciting and intense, ending with a whirlwind of needing to do a breathing treatment on someone and finding it’s already 6pm and you’re alone in the building with the patient. And damn if you know how to even find the machine.

Today was about the guy who really wants to talk about erectile dysfunction. And, oh, there’s blood in his stool and he had a heart attack in the last 10 months since he saw a doctor. And diabetes and hyperlipidemia and uncontrolled hypertension. But let’s talk about erectile dysfunction, and toenail fungus. And my favorite almost 70-year-old, who was doing well, by gosh, up until she started falling over last week. A let’s-help-you-not-get-pregnant while-you’re-still-using-cocaine discussion. And a your-skin-is-just-dry-try-lotion pep talk. And then an OB visit. Covering for another provider. Third trimester, pregnant after failed tubal, uncontrolled epilepsy, hasn’t heard back from neurologist, malar rash not going away, positive ANA screen, GDM with broken glucometer, elevated blood pressure, hypothyroidism. 15 minute appointment: go!

My 21 year old type 1 diabetic with sugars that were either 65 or 270 seemed positively glowing with health by comparison.

Next came lupus. Confession: I am afraid of rheumatology. It is like a black box for me. Here is what I know about lupus: the name sounds like the latin for wolf. You need 4 out of 11 things to diagnose it. There is not room in my brain to remember what those 11 things are. It is bad. Different organs can be affected. Women are disproportionately affected, much as we are with lines in public restrooms.

So now I’m managing lupus. Because it’s me or no one for this young man without insurance and who missed his consult appointment because it cost $450. And I’d phone a rheumatologist to curbside but it’s after five.

Here’s what I can do. Print a patient information sheet in Spanish from the aafp website. “Thanks for coming in guys. I don’t know what the f*** to do but here’s some informational pieces of paper to freak you out a little. See you in a few weeks.”

And I thought I was done. But the two nurses found me in the dictation room trying to work the printer.

“Your last patient has a blood sugar that won’t compute on our machine which means it’s over 500 and he wants oxycodone and says his pain is why he isn’t taking his insulin and it says here on his chart ‘do not give narcotics.’”

WHAT??? “Um, last patient?” It’s 5:45. Everyone has left the building.

The nurses recommend to him that he go to the hospital. Thank. Goddess.

And that, my friend, is Friday. I consider myself lucky. I had a hot date for my birthday already lined up. After dictating in record time I made it out to the fancy-pants restaurant GB had picked out.

The waiter recommended wine pairings for the food we were eating. I couldn’t stop giggling. GB gave me the evil eye. “This is what I do all day,” I told him. “’Here, try this. Here’s your diagnosis, and a prescription to match.’ And I look really sincere and scientific about it but really sometimes it’s just a guess.” Fruity ketone notes with undertones of bilious emesis. Best paired with insulin and IV fluids. Now lupus? Hmmmm. How about a gin and tonic? Giggle giggle snort.

Obviously I do not get out much. Nor should I be allowed out.

Call 5

Connected

Well, that's it I guess.  The honeymoon is over, and I'm a resident again.  At least it feels like it.  Call was brutal.  Pretty much everyone in the hospital was my patient.  Stayed up all night wandering bleary-eyed around the nursing station and dashing into rooms for sudden fetal bradycardia after epidurals and such.  Reminded pregnant people not to use cocaine anymore.  Got yelled at by obstetrician on call.  Yep, exactly like when I was a resident, except none of my resident buddies were also suffering in the hospital with me.  Couldn't just escape to the medicine call room or find any disgusting low-fat cheese to eat.  Didn't have the Dragon or associates to run my thoughts by on the preterm IUGR with low AFI and h/o stillbirth.  In a word, it was... lonely.

I like the nurses.  While I was shooting myself for not having long-enough fingers to do an adequate cervical exam on a lady who was contracting with 2 previous c-sections, K was self-flagellating for allowing the same patient to eat 3 bites of a sandwich.  We sat at the triage station together and stared blankly at the repetitive variable decelerations of another patient I was inducing (and slowly, they went away).

Then I ran up and down the stairs several times to the ER to evaluate a couple of kids, and admit one.

By 1am I could almost take a nap.  I got ready to send a triage patient home, a woman at 23 weeks with round ligament pain.  Then I found out she had had 2 previous 2nd trimester fetal losses.  She had no contractions, and her cervix wasn't changing, but she was visibly shaking.  She wanted this baby so badly, and she was terrified she would lose it.  I decided to run a fetal fibronectin, and I laid down for 30 minutes.  It came back negative, which means there is almost no chance she'll deliver in the next 2 weeks.  It felt good to be able to tell her that.  She went home.

Immediately after, it was time to deliver another first baby, who decided to enter the world with the umbilical cord wrapped tightly twice around his neck.  He had a rough time for about 30 minutes, so I was keeping an eye on him while sewing up a bleeding perineal laceration.  The nurses calmly helped him out, and adjusted my light.

As we finished with that baby, the patient with preterm/IUGR/grand multip/no prenatal care/cocaine combo returned, this time in labor with light meconium in the fluid.  I called the pediatrician on call to stand by.  That baby delivered, and it was an absolutely beautiful delivery.  It really was.  And she was a beautiful girl, who came out yelling and transitioned just fine.  She had the longest eyelashes I've ever seen on a 4-pounder. 

Next I let the lady with the previous c/s go home, as her contractions had stopped and she'd had some rest.  The day team was arriving, and I signed out to the next doc. 

As I left the floor, K was back, starting her shift and signing out with the night nurses.  I overheard her asking about the patients we'd seen together.  How they were, if they'd delivered, if they'd been able to go home.  And I realized, that's what we all have in common.  That's what keeps us coming in to work every day.  It doesn't matter how crazy it is, or what a wreck our lives are, or if it's 2 am, we're all just looking to connect with other people.  Even for a minute, or a few hours.  Each of those connections changes our life in some minute way.  I know every time I leave the hospital after a call I've been changed by those connections.  I smiled to myself.  And I felt a little less alone.

Third Spacing

Call Home

Had call over the weekend on Friday.  So when I might get called into the hospital, and I'm sitting at home next to my phone, I might as well be in the hospital.  Or maybe Egypt.  I'm of no use to anyone, at all.  I pace the floor, I pace the internet.  I can't focus on my kids or on my husband.  I'm third-spacing my thoughts, which means my brain is in the jet stream of collective consciousness located between the hospital and my house. 

My family naturally reacts to this by trying to pull me in even more directions.  When the resident calls me to report on a patient in triage, GB takes the opportunity to talk to me THE ENTIRE TIME I'm on the phone.  When I try to read online about a patient, Beastie sits on my computer, or my head.  Cats do this, too, you know.  It's their way of ensuring world domination.  Or trying to connect with you.

 

Being on call is like the opposite of connection.  It's about being available, for anything to do with patient care, anytime.  Whereas connection is really about being unavailable to everyone except the One you're connecting with.  The more you're trying to connect with someone the less available you are to other people.  But if you need to be ready for anything, best get the phones and the computers all lined up in front of you and stare blankly into space.

It would be nice to go for a run and get all that distracted energy out, maybe then focus and be more grounded for whatever the night holds.  But I can't run while I'm on call and still be within 20 minutes of the tower of doom.  Unless I run TO the hospital.  Yeah, that would be awesome.  I could show up for delivery in scrubs and sweatbands.  Maybe they make scrub shorts or running scrubs.

Went to sleep at 11 after had read everything on the internet.  The kids were still up wrestling or snorkeling or something.  At 2:30 got called for a multip presenting in labor at 6cm.  Ah, finally.  Now I could go to the hospital and Do Something.  Showed up and peered over the resident's shoulder while she wrote progress notes.  Another multip arrived and delivered right after I got gloves on.  See, this is why people are on call.  To be Available to Do Things like Hand People Their Babies.  The rest of the night was spent waiting for the first woman to deliver, and hanging out with the resident.

The resident recently went through a divorce.  We talked about relationships within medicine.  She'd read in a book that when you're in medicine you're always working toward the next thing.  When you're done with medical school, things will be better.  When residency's done things will change.  If you can just get through this rotation, or call night, then your life can begin.  But relationships aren't like that.  There's no "goal."  There's no point at which you've arrived.  Nowhere does love just get easier.  And if you keep putting your love on hold or trying to work toward some "goal," things will just fall apart.

That explains a lot.

Are medicine and family even compatible?  At one point I would have said absolutely not.  At one point not so long ago I thought I was going to have to choose, and that I might lose both. 

Now I think there need to be boundaries.  When I'm at work I need to focus on work.  When I'm home I should not also be at work.  Instead I need to be fully present at home.  But then what about home call?  This is a contradiction in terms, methinks.  It's going to take a while to sort out. 

And then, maybe when I sort it out, my life will FINALLY get easier...

Pain, first of many

Miracles You Don't See

Let's be clear about a few things.  If you are found outside the hospital in a car not breathing and we have to code you or call an ambulance because you took too much of your oxycodone, I'm not going to give you any more. Period. NO. You clearly are dangerous with that stuff.  Also, a minute ago you were driving.  And I have little kids.  And they were also maybe on the road.  I mean with their father, of course, driving.  So, to summarize, no.

And it was thus that I had the following discussion at least twice this week, with different people:

You:  So I need a refill of my oxycodone.
Me:  Oh, really? Hmm.  Well, I've been meaning to talk to you about this.  Actually maybe we should talk about that medication again.
You:  Well, it's the only thing that's helped.  I've tried everything.  Believe me.
Me:  Oh, like physical therapy?  And acupuncture? And OMT? And exercise? And weight loss? And an anti-inflammatory diet? And tricyclic antidepressants?  Or NSAIDS?  Or meditation? 
You:  I'm pretty sure I tried all of that.  I don't know what it all is, but I'm sure I tried all of it.  Because I've tried everything.
Me: (avoid eye contact, look at chart) Uh...
You: Once I saw a traditional Kazakh hypnotist who introduced me to my spiritual analogue, which is a unicorn.  Another time a Honduran pool boy recommended I snort some penicillin, which I tried.  None of that stuff works.  Oxycodone works.
Me:  Ok.  So I hear you saying that nothing else works but the oxycodone.
You:  Yep.
Me:  Ok.  But the thing is, you took too much recently and passed out in your car.
You:  Well, no one told me I shouldn't also take a Valium that a friend gave me.  So that was a mistake that now I will never do again.
Me:  Ok.  So I hear you saying you will never do this again.
You:  Yes.  Sure.  I'll take any drug test, doc. Every week. I need this. It's the only thing that works.
Me:  Ok.  But, wait, this is ridiculous.  I can't give you this medication anymore.
You:  What????
Me:  No. I can't give you this medication...I have a personal policy to not...I mean, you passed out in your car.  Like a week ago.  I'll lose my license.
You:  But it was a mistake!  Come on, you can't do this to me.  It's the only way I can function.  I'll go into withdrawals!  You just don't understand what it's like!
Me:  So I can't do it.
You:  I can't live without it!
Me:  So I don't know what to do then.
You:  So I don't know what I'm going to do!
Me:  There are some things, you know, like you could go to physical therapy again, or... like,
You:  Dude.  I tried all that.
Me: (Thinking to self: well, maybe actually this is the only thing that works.  Maybe I'm just not being empathetic.  Maybe you did learn your lesson.)
You:  Really, it won't happen again.
Me:  But.  I have kids.  You could have been out there on the road and crashed into my kids.  So, no.  Not going to prescribe this medication.  Anyway, studies show that this medication is no good for chronic pain anyway and I can work with you to find other modalities that...
You:  Fine.  I'll just find another doctor.

There is a lot of pain in the world these days.  And I'm extremely lucky to be not truly able to understand where folks are coming from when they talk to me like this.  I want to understand.  But probably I can't ever.  There's physical pain, chronic, gut-wrenching, raw, tear-your-eyes-out pain.  And there's what the Falcon calls "existential pain."  And it seems like narcotics help a little with both.  But only to a point.  They numb.  But, try doing anything with a limb, or lip, or mind that's numb.  Life can suck, and some folks get the brunt of it.  I honestly don't know how to help these people.  At least, not if all I have to work with is oxycodone.

These are the worst of clinic encounters.  No one is satisfied.  Nothing gets fixed.  We go around and around until someone leaves the room.  It makes me sick, it makes me sad.  They cry, I fight back the tears. 

Three years ago, a kinder, gentler, intern version of myself wrote this poem to describe this relationship.

To the unbeliever: miracles

do happen but tonight

your tired eyes cannot see

the pain that wraps me

like a child around myself

and collapses the universe

to a tiny point

your outstretched hand

offers me. I accept

your skeptic gift

and feel the miracle

of life wash over me.

maybe

tomorrow this agony will

be over, maybe tomorrow

never comes, but

please oh please

don’t stop

please don’t

stop

believing.

 

Hospital-ed

Death, or Birth

 This week I've been in the hospital.  It's fine.  In many ways I've gotten a lot of other things done because it's not so busy as seeing clinic patients all the time.  A few couplets to round on here and there, someone to induce, someone else to rule-out preterm labor in.  There are some old ACOG green journals in the call room which I've been perusing, and reading "journal watch" online for the first time.  Mostly though I've tried to catch up on life things like responsible people do.  Like figuring out if I have car insurance anymore.  And oops, I don't.  Like getting my eyes checked.  And then realizing I've lost my sunglasses, and having to drive home in a near-total white-out of blazing sun.

The other night I delivered a baby without breaking the membranes.  It was a really nice, induced, but otherwise natural birth.  I didn't break the bed down.  The woman did beautifully.  The nurse working with me that night commented to the student nurse about what a nice "veiled" birth it was.  We got to talking afterward about how long she'd worked here (19 years), and I told her she'd have to help me find my way around.  She told me she initially was in pharmacy school, but everyone she talked to in that field felt like they were in some sort of assembly line/factory.  She got out because she wanted more patient interaction.  First she was a tech at the hospital, then she went to nursing school.  And she loved it.  Now she also has a farm near the hospital with 60 chickens, and she gave me some eggs for my kids.  I told her I was looking forward to working with her again.

This morning as I was sitting at the triage station I learned that she had died, unexpectedly, that morning.  The nurses were all in shock.  I know it's not my tragedy, and I barely knew her.  But it really reminded me of the frailty of life.  It could be any one of us.  We're no more protected because we're in the business of bringing new life into the world. Death, like life, is random.  And devastating.  It never gets less so. 

A few minutes after I heard the news, there was a "CODE BLUE, PEDIATRICS" page.  I grabbed the closest reference book I could find and ran toward the door, hoping against hope it wasn't my patient, the one we were rehydrating for gastroenteritis.  "Shit," I said, as I thought about gastroenteritis, and codes.  When I got to the ward, the nurses said "all clear."  It wasn't my patient, and everything was fine anyway.  I wobbled back to the call room and sat down.  I googled all the PALS courses in the area.  Really need to take one of those.  Probably also ATLS in case anyone falls down in the hallway.  Shit.  I forgot I wasn't actually prepared for every possible contingency.  Maybe if I just know enough algorithms, it'll all be okay.

(But can you ever really be prepared for death, whether it's yours or someone else's?  Or life? Or birth?)

Psittacosis

Getting Worked

Yesterday was one of those days.  I got worked.  I showed up to work, and I got worked.  This was big-kid medicine.  In an attempt to gain some control of the situation, I followed the advice of many sage and elder doctors before me, and wrote down my clinical questions.  The trouble is, I couldn't answer even the most pressing because THE INTERNET was BROKEN.  What?  I thought the end of the world was going to be in December 2012.  I was not ready for this.  And it's not like I have room in my doctor bag for Harrison's Textbook of Internal Medicine and Williams Obstetrics and that other Pediatric text what with all the diapers and Thai coins and ACLS cards and 57 different name tags in there.  Here is a small sample of the things I want to review from yesterday: How to safely taper patient off s***-load of diazepam patient has been taking for 10 years while avoiding seizures and panic attacks. How to convince patient this is a good idea. Does Mirena cause low libido?  I know "it doesn't." But does it? How to know if a headache in a hyperactive kid who's been exposed to NAT 9 months ago is ominous or not. It was a day of breast lumps, profuse diarrhea, hypoglycemia to 25.   It was a day of telling people all day long to drink water only, and no soda, and not to eat cookies.  And spending so much time on nutritional advice that for lunch I didn't have time to go to the natural foods store.  So instead found some cookies and soda.  Really. And I hid in the corner and ate them.  On the plus side I walked out of a room to find someone had brought their pet hawk along to their doctor's appointment.  He demonstrated how not to get the bird to bite you.  He had a cage, leather gloves, the whole bit.  If I had known it was show and tell I would have brought my.... rock collection? Who am I kidding, I can't top that. My last patient of the day came in concerned for breast lumps.  Turns out she'd also had some systemic symptoms lately, fever, and diarrhea.  Or not.  Sometimes people live with a vague idea of what is happening in their body, and sometimes you are meeting them for the first time.  The hardest thing in our job sometimes is to decipher what's really going on in someone's body (and in their mind).   I was sufficiently concerned.  I fell back on my triage basics.  Hospital or no?  Urgent work-up or non-urgent?  I decided what I needed to do and discussed with the patient.  She agreed, then I ordered the appropriate labs, imaging, and referrals.  Then I left the room and went to look for cookies. The lab folks found me soon after and told me the patient wasn't going to be able to do the labs because she couldn't afford them.  And if we could only do one or two, what would they be?  I hate these sorts of decisions.  I mean, are we in the developed world or not?  Why should how I treat people depend on their ability to pay?  I like to think it doesn't.  But if they can't afford something and so I cancel some of the labs, then it does.  It just does.  This sucks.