I wish I had a dermatologist in my pocket. Instead I have syphilis.

Wednesday was Rashes No One Has Ever Seen Before Day.

A lovely pregnant patient came to see me complaining of an insect bite. It was not an insect bite. Unless insects bite you only on your groin and instead of creating a small pink welt they cause grouped clusters of yellow or blood-filled vesicles crossing several dermatomes and only mildly itchy or painful. I got out the atlas. Then I pulled in the Dinosaur. “I don’t know what that is,” he said.

 Awesome.

In the hospital on call a VBAC awaited. Her bag of waters broke early in the morning and there was thick meconium. She had no contractions yet. This is called PROM, only no one wears fancy dresses, least of all me. The nurses needed me to talk to her also about why we weren’t starting her on Pitocin to induce her. The reason is because it increases your chances of uterine rupture from 4 in 1000 to 11 in 1000. And uterine rupture is a bad thing, since it has at least a 10% mortality rate for baby. But the longer we wait the longer we risk infection, which is more likely, just less dangerous. And she could always opt for a c-section, which is less dangerous for baby on all accounts, but riskier for mom. So, a complex discussion to be sure. Try doing it in your second language.

Arguably more fun than regular prom, though.

After I finished the nurses asked me to stay for 2 minutes and translate for their assessment. They have no translators today. They are woefully understaffed.

I needed them to watch my strip for me because I just got called to the ER.

Dr. ER Green Zone had a baby for me to opine on. “He won’t move his arms. He’s 8 weeks old. His xray looks weird. I’m not sure what it is.” Cool. I’m sure I’ll figure it out right away since I know so much about orthopedics in 8 week old children.  We look at the xray right away. The distinguished radiologist has created a differential diagnosis for the diffuse periosteal inflammation that includes several vitamin deficiencies and a disease I have never heard of, Caffey’s. I go in to see the patient. He’s cute, but he hates it when I touch him. His arms seem weak. And there’s a weird rash on his arms.

I should have put on gloves, but the rash is unexpected. I touch the soles of his feet, where the skin is peeling. A scalloped red border extends to the sides. There are plenty of raised pink and red bumps, but in circumscribed areas. There are some ring-shaped lesions. It looks for all the world like nummular eczema, except the two spots that look like ringworm, and the spot on his chin I can’t convince myself isn’t an early herpetic lesion.

Shit.

I ordered some labs and started reading. I asked Swiss to come look at the rash, too. I called the patient’s PMD, who took care of his mother in pregnancy. She came late to care and never did her labs. The hospital drew a paltry few when she was in labor.

I decide it’s syphilis. Swiss, the resident, the medical student and I go back to the ER to take another look. We keep refreshing the computer screen waiting for the RPR to come back. I call the lab. “Oh it is send-out. 3 to 5 day.”

I ship him to the University hospital. He deserves specialist consultation, which we don’t so much have here. Not for derm, not for ortho, not for 8-week-olds, anyway.

The VBAC PROM is still hanging out. I go home and take a nap.

At 1 am a woman arrives at labor and delivery and goes from 5 cm dilated to delivering a baby on the floor in 10 minutes. The resident was sort of in the room at the time.

And then… nothing. My hands may have syphilis. It is not confirmed. That is all.

Good thing I don't smoke.

Had a delivery last night that I think shaved 2 years off my life. 8 minutes of terminal bradycardia, probably more but the nurse was lackadaisical about the FHT and wouldn't get me an FSE. And I had to ask another nurse who got me an IUPC instead. And the woman was so Mg-ed out we couldn't move her side to side. And then the first nurse told her she just needed to relax and I said "no, she needs to push this kid out" and finally she was barely +2 so I vacuumed the kid out and then he was gray and the nurse said "he's just stunned." and then we resuscitated him.

And then I forgot the name of the 4x4s for the repair and all I could do was ask for "more of those white things. The little ones."

Oh, and there was a resident.

Grown-up

Today I wanted to cry at work. There was no one moment that made me feel that way. No time where it was close to happening. It just felt that way. Maybe it was my upper lip, next to the left side of my nose. It kept twitching, and made me feel awkward talking to people.

It’s the lip quiver I also get just before I do cry, when I suddenly can’t control the words coming out of my mouth. It’s the tremble I saw in my own dad’s face last weekend as we left my hometown.  We were eating burritos at Taco Time. “I just realized this morning how much I miss you guys,” he said. There were tears in his eyes. And I don’t know but this might have been the first time I’ve really seen him cry. I think he has before and I always looked away, trying to be polite. But I looked at him and I didn’t fall apart. I miss him, too. But I have my own little pieces of my heart running around and filling every waking moment. When I think about them one day having their own lives and leaving my home to visit only a few times a year, well, then I can understand.

Work sucked today. Let’s be honest, it’s not been as much of a picnic the whole last month. We started with our Electronic Medical Adventure about 5 weeks ago. Since then I’ve been overbooking my schedule to see everyone, at the same time helping everyone else learn to use it and building templates into the system so that one day we may stand a chance in hell of getting back up to previous productivity levels.

I hate it. I don’t use that word very often. I hate this.

I don’t even like computers. I want to be outside, playing in the creek. Other providers have complaints and concerns and I feel like I need to be supportive of the system and the administration, but I don’t know why. This medical record system sucks. I told them it did before we even chose this one.  All transitions are painful, but the pain might never leave us with this system.  And now I’m a Super User. Somehow it’s made me feel like I need to act like a grown-up, not gripe, stay late, be a team player, be patient, be energetic.

Patient A complains no one called her back when she was suicidal.  So I say “Boy, I’m sure sorry about that. I never got no darned message about you wanting to kill yourself. I’ll put in a word with the triage nurses.”

Patient B’s blood pressure is 160/80, previously well-controlled. “My pharmacy said you denied the prescription refill, so I never got the med.”  So I say “Oh, durr. Silly computers. Of course I want you to take that medication!”

Patients with real illnesses are sent home without being seen by a provider. Others are sent to the hospital for not feeling their baby move before 20 weeks. Which is normal in humans. No one can find any paper charts, but nothing is populated into my electronic chart.

I’m fucking sick of it and I’m terrified that at any moment something catastrophic could happen.  Everything is entirely out of control.

But instead of saying so, I act like a grown-up.

Here’s the thing, though. I’ve been acting like a grown-up for the last 5 weeks. And feeling more or less like a functional adult, instead of a 12-year-old on Career Day. And it’s entirely overrated.

The more grown-up I am, the less human I am, I think.

I want to cry, for the pain of my patients, for how out of control this raging machine is. Instead, my lip just quivers as I smile and offer empty apologies.

I want to cry, for every night I stay away from my children because of internet connection delays, or making calls to return to disgruntled patients, after everyone else has left the building.

Instead I’m a grown-up now, watching my dad cry for all these reasons in a career only 24 years longer than mine.

Back

Years ago I worked in the woods every summer, next to a lake. The days were endless in North Idaho, and it was light from 4am until after 10.  The water, chilled in early June as though the ice just barely cleared, was 75 degrees by August as it rolled over our golden skin. At the end of the day, we’d clear the swimming area of kids, and send them to shower. Then we’d backflip off the lifeguard tower, or jump into the boat for a quick ski around the lake.

In those days there was so much to believe in. My legs were strong and there was God and night would always fall slowly like the way my Midwest relatives say goodbye. Most of all there were all of us, working 18 hour days together under the sun, to make people, kids, happy. There was this common goal, so there was community. I was never alone.

A world later, I found it again, in the place you’d least expect it, residency. In the hardest months of my life I found them. Earnest folks who know who I am and what I am capable of, and somehow still believe. In me, in medicine, in the joy that is working together.

It was hard, sure. The work took everything I had and more. And I’ve said before the toll it took on my family nearly broke us. But in those days, there was so much to believe in, even when I didn’t believe in myself.

Where I live now it’s different. There’s less cohesion, less inspiration. Belief in anything is optional.

I’d been gone a year. I feared I’d been forgotten, that I’d forgotten everything I learned.

And then I went back to the place where I became the doctor I am today. I visited all the familiar haunts: the hospital, the sacred sign-out place that is the Falcon’s office, the call room, the clinic.

I must have looked weary to the Dragon when I met him for lunch. “What’s wrong?”

“I’m just tired,” I said, and ordered a pizza. Later I mumbled that I might be less than excited about my job.

“Tell me a story about a patient,” he said. An attempt, I think, to inspire me, remind me of what I do love.

I told him about Potter.

Which of course is the worst patient story from the last 8 months, but it was the only one I could think of.

It’s unfair to blame this dysthymia on external forces. There’s something I need to learn here, some way I need to grow.  But I miss these people, like I miss the Idaho summers of my youth. Not for the work itself, but that it was made bearable by a community. These people give me something to believe in.

It’s a crutch. I need to believe in things myself. I need to inspire, not just to be inspired. Maybe I need to be without my people right now so I have something to offer when I move back and establish the commune.

See, I want to work with these people again, share practices and overseas projects with them. We should all buy a piece of land with yurts around the periphery, a garden ringed with daisies, and Shaman will create a series of baths. The Visionary will inspire me and Haiyan will stretch open my mind to the world, and my kids will be raised by a village. We’ll call it Yurt Village. We’ll have matching tattoos.

It’s sort of a joke. Except I mean it. It would be neat.

A half hour later I somehow found myself in Vasectomy clinic, a syringe and a Li clamp in my gloved hands. Ceci, a year behind me in training, invited me to do her surgeries for her; she doesn’t want to learn them. My clinic needs me to. She handed us instruments. The Dragon stood across from me.

I operated successfully on two men. It had been a year, but I remembered the techniques, and learned the updates. Plus, I was a visitor, but I was home.

And something had changed. I don’t think Ceci saw it, I don’t even think the Dragon noticed. But I was no longer a resident, across from my mentor. I was an attending. I was thinking each step out for myself. I didn’t wait for the instrument to be selected for me, I asked for it or took it off the table. When there was bleeding I moved to control it.

It was an unexpected boost to my faltering ego. I got to see, for a moment, how far I’ve come.

Huh. And most of that came out of being mostly alone.

And then I went to the woods, which was the real reason I was in town. The Visionary was getting married, after all, next to a lake. We swam and canoed, and slept late under the trees.

Love vs. Drama

Termite forgot her anniversary. We laugh about it, because that’s what you do when you can’t believe you forgot your anniversary. What, should we be crying?

Drama seems to surround us. A colleague’s contract was non-renewed, for no reason anyone knows of. She’s the only Suboxone provider for our practice, and for our poorest patients. Leafy might leave our practice, because the Linebacker’s ER job is getting worse every day.

My own life seems remarkably normal.

Termite has had enough of her husband. She just wants to be happy, and it isn’t so at home. She thinks she’d be better off alone, raising her kids herself.

I don’t know what to tell her.

My next patient looks very Mayan. We exchange greetings, but she gets right to the point. She needs me to check a rash. It’s probably herpes: that’s what she was told before. She got it from a man. Not her husband, mind you. No, he’d never do that.

Five years ago she arrived here alone, hoping her family would soon follow. She didn’t follow all the rules, of course, because these days that’s hard to do. So she was without “papeles.” But she had a job. And she sent money to her two kids and her husband.

There was a man at work who took notice of her. She didn’t like it. She told her coworkers, who laughed at her and called her a drama queen. He took more notice of her. Then he took advantage of her.

She doesn’t speak English. She was afraid of the police. He played into that. He threated to report her to La Migra if she told anyone.

This went on for five years.

Of course she was depressed, of course she felt like dirt. He made her feel that way. Obviously she was trapped.

Her husband and kids finally were able to move here as well.

“He’s a good man, my husband” she said. “The best.” But she couldn’t touch him, barely could look him in the eye.

A friend from the Laundromat finally took her aside, ostensibly to help her move some furniture. “You’re sad,” she said. “What’s going on?”

And it broke the ice. Now she’s in counseling, her husband finally knows. Most days she’s on the path to healing. She brought charges against the man, found out he’d done this to 6 other women. She can’t have a normal sex life, she can’t breathe sometimes on bad days, but it’s alright. 

Well, it’s not alright. But she’s alive, and what’s more, she finally wants to be.

When you walk into a room and close the door, you have no idea what world you’re about to encounter. Pain, joy, anxiety, insomnia, anger, mania, hyperactivity. Then you have to leave the room and let it roll off you so you can walk fresh into another world. It’s not that easy, you know.

The words of another patient come to mind. She’s gone admittedly “a little wild” since divorcing her husband. There are bruises on her body, consensual. She occasionally gets PID. She wonders if she might be bipolar. She wants to find out, because “Our job in this life is to be happy. And that is our own responsibility. So I want to find out how I can be happy.”

Me too.