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.