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.