Implements

We’re “Implementing” an “Electronic Medical Record.” An electronic medical record is an exciting new way of storing your patient’s medical information in a brightly colored and incoherent and less efficient fashion. Basically it’s like hiring people who are high to do your filing.

And you aren’t high, you just wish you were because you are working 50% more hours than previously with the same pay.

Having an Electronic Medical Record is important because it is The Future. Also, because the government will pay you to have one. Also because “Meaningful Use.” Meaningful use is where you have a password and you have to try to guess it on a website and then you have to call a lady during work hours and wait for 30 minutes on hold and then authorize her to give your company $10,000 for you to use a computer, meanwhile your patients are piling up in the waiting room like so many angry ranchers in a stockyard.

If you don’t have an EMR, all of the patients will look at you like you’re incompetent dinosaurs applying leeches to wounds and diagnosing “Hysteria” and performing exorcism on patients with cirrhosis. The lab will use chisels to draw bone fragments out for analysis.

If you do have one, all of the patients will look at you like you’re a robot who cares not to look at them during the patient visit and spends most of the time in communion with the wall-mounted machine. Which communion sounds something like this: “I’d rather have a cystoscopy than use this fucking computer program!” To quote Dr. DDx.

After hours, you and your colleagues will continue to labor, bent over the keyboard, brows furrowed.

And you might take comfort, because previously you were the only one there after six.

But then it’s seven, then eight.

You overhear your colleague on the phone. “I know you need your prescription for Norco, but we’re closed. So I’m going to send it to the pharmacy using this computer…..”

Pause for 4 minutes.

“Okay, actually that didn’t work. Now I’m going to try to fax it using this computer….”

Dramatic pause for another 3.

“Okay. Screw this. You at home? I’m coming over on my bike. Be there in ten.”

And that, my friends is the Future.

24

What a day.  Only 5 patients this morning, and it was all I could do. 2 OB’s needing NST/AFI’s. One of course presented at 39 weeks without any prenatal care from our group, with pre-existing hypertension on medications, and without any prenatal records. She’d like to be induced Friday, please, but she’s not sure when her due date is.

Next another patient with severe back/left belly pain. It’s not her pelvic organs, or her gallbladder; those were removed a while back.  It may be something around her kidney, like the liquid she had removed twice with a needle several years ago, now that she thinks of it.  I’m not sure, as I talk to her, that it isn’t actually from her heart. But I am sure that something is wrong with her. She can’t smile, or really move her face at all. Tears come early. She’s anxious, can’t sleep. Nothing is fun anymore. She’s guilty about everything. Energy is gone. She can’t concentrate.

She has lost 30 pounds over the past several months.

She thinks about driving off a cliff nearly every day.

She hasn’t seen a doctor in 7 years. I guess I’m it, then.

We do an EKG, and I examine her. I grab the therapist from her office to see if she can stop by. She does. We make a plan, and order labs and a follow-up appointment. Then she’s gone.

Later I stop by the therapist’s office to ask how the discussion went.  “She sure is depressed. Also, guess what she’s drinking every day?”

I brace myself for the inevitable unearthed alcoholism that the patient had denied previously. I’m wrong.

“24 cans of Pepsi. A day. 24 cans. I asked her three times to be sure.”

What?

Leafy stops by after clinic to catch me staring blankly at the 30 charts on my desk. We talk about the drama currently happening among the staff.

As we leave the building I tell her about the Pepsi. She acknowledges sometimes you just don’t know what to do. Today, her patient complained of being run over by a Studebaker. Which crushed his penis. And now he wants to have an erection.

“But I don’t even know what even will work?”

“Well, can I just have some Viagra?”

“Sure.”

Dangerously Close

The first few months of medical school are consumed with anatomy, biochemistry, and cell biology. Histology, maybe, and the physical exam. Most of those classes are a hazy, pleasant-ish memory to me now. For example, the elderly pathologist who lulled everyone to sleep by reading directly from his overhead slides in an unruffled voice until one day he exclaimed “What’s this? Well by golly it’s a Howell-Jolly Body!” At which point I woke up for 5 minutes.

But somehow no one ever forgets the anatomy lab. It’s recalled with perfect distilled clarity every now and again when I catch a whiff of formaldehyde or phenol. Like, just the other day as I was ablating a portion of my patient’s toenail bed.

I turned my head away from him for a moment. “Es que este olor… bueno, nada mas que no me gusta mucho.”

Before my oblivious patient I was suddenly 22 again, in a room of dead bodies, drenched in repulsive sickly sweet preservatives. Immersion. Handed a scalpel. Told to cut. Against every instinct in my naïve little heart. White as the sheet that used to cover this respected elder who gave her body to science, to us, now lying naked.

Suddenly with a clipboard staring bewildered in the mid-term at tags tied to tendons. Rotating after each “ding” to the next cadaver, longing for my own, whom at least I knew. Willing, teleporting myself outdoors into the blinding heat and late-summer stillness just outside the window. Lost in the last dying days of my childhood. The days when I knew enough and knowing wasn’t everything, anyway.

Wishing there was some sort of mid-term that might test my knowledge of kitchen implements, or garage tools, so I might feel like I knew something at all. Then confidently I could write “This, Dr. Professor Sir, is a measuring cup. 1/3 cup to be exact. Exhibit #35 by contrast is a sieve.”

Staring into the abyss of What I Need to Know. At the crossroads of earnest interest and imperative mastery, the fear of failure gives you the courage to don a white coat and with it delude yourself into believing you’re impervious to pain and death.

I made it through the class.

Several months later we started Neuroscience. After a few lectures we were sent back to the lab. Nothing, not the white coat, not the desensitization of anatomy class, could have prepared us to see our lady’s brain lying neatly on a cutting board. A single serrated bread knife was on hand.

We were told to cut. Sagittal sections, about a centimeter apart.

Nervous laughter.

“So, who wants to cut open the brain?” I offered. No one took me up on it. “I’m not doing it myself.” The holy grail of humanity, the sacred seat of the soul, the great mystery of consciousness. We’d been told the consistency was like tofu, the extra firm variety.

Years ago on an ornithology field trip in the middle of a 30-mile salt flat a group of girls had to pee. Wordlessly we spread into a circle about 15 yards across. We faced in, and all went together.

Somehow subverting our instincts is easier when we do it as one.

I made the first cut. Then I passed the brain to the left, and my partners, in sequence, took their turn.

That weekend I went camping in the desert. We took a guided tour of some caves. In the dark among strangers, it was all I could do not to blurt out “Say, on Thursday I cut up a human brain.”

Why? It felt like a confession I needed to make. Like it might absolve me of the crime. Also I wondered a little what they all might think if they knew.

All I was trying to be was a doctor. I felt like a monster.

I said nothing.

Now there are a million moments like this that set me apart. Horrors we see and do every day that give us an air of mystery and a privileged place in society.

My landlady works with veterans, as a psychologist. She’s busy at the moment with the returning Iraq and Afghanistan troops.

She sat opposite me on the couch. “They are all suffering so much. So many of them have anxiety, panic, PTSD. They’ve seen such terrible things, it’s like they can’t be normal again.”

“Is it all of them?” I asked. “Do you think some will turn out to be okay?”

“Well, I worry more about the ones who seem unaffected. Those are the ones who do worse. Humans can’t see that kind of devastation and be unaffected. If you’re numb to it something’s wrong. Those are the sociopaths, the killers.”

The ones who can mutilate a brain and then casually go on a cave tour. The ones who can pump on a teenage chest for 30 minutes and then give up and have a sandwich. The ones who can look into the eyes of a heart that’s breaking and feel nothing, and glance up at the clock.

My God, what sort of “healers” might we be at the end of all this? To stay alive in this profession we’re strategically deadened. Afraid for our own survival, we jump through all these hoops. Some drop out. They’re “weak.” We’re worn down to exhaustion working night after night, so we never complain. Worn down to the point we’re relieved to see that the struggling cirrhotic has died overnight and we have one less patient to round on in the morning.

Did I just say that out loud?

Outsource the empathy to the nurses, folks, because there’s nothing left here. Nothing but an empty, encyclopedic brain and beating, mindless heart.

Can it be true? Has it all been bled out of me?

See the patients faster, Doctor, that’s not fast enough. They might cry, they might beg, but you’ve got others waiting. Give them a piece of paper, they’ll be fine.

You’re just trying to take on too many things. Set a reasonable agenda. Tell them to save the other 8 items for next time.

That baby just died? Here’s another one on the way. This one needs to be removed surgically. And the answering service has someone on the line who’d like to know what flavor of pudding to mix with ciprofloxacin.

She has cancer. He’s suicidal. She’s had her foot removed. Talk to them, sure, but no more than 10 minutes apiece.  She’s been kicked. He’s addicted. She doesn’t understand her diagnosis. His cat just died.

I’m neck-deep in charts and urinalyses. What the cadaver horrors didn’t drain from me the endless ticking clock will. This is primary care. This is the trenches. I’m dangerously close to numb.

Fortunately, so is his toe. It took a bit of extra lidocaine but the digital block worked. He’s smiling. The ingrown toenail was a pain. He’d tried to remove it himself with pliers. Apparently I did a slightly better job.

I believe I’ve killed the nail bed with phenol. My soul may yet survive. Maybe.

*Note: the suffering and death seen by most physicians pales in comparison to the trauma experienced by many veterans. I don’t equate our lot with theirs, and I give them the credit they are due. This was written merely to make an interesting comparison. And, mostly, to hold out hope that humanity and empathy can be reborn, even when all seems to be lost.

Waiter

coffee

I read somewhere about endorphins artificially causing people to fall in love. Adrenaline, and then the presence of someone, can later cause you to feel that same rush whenever they come around again. This was probably not in a major medical journal that I read this.

Coffee increases adrenaline. I love coffee.

I need it lately. It may or may not need me.

I don’t remember what the surface of my desk looks like. It’s always covered in a pile of charts. Sometimes, on good days, I leave the office with just a single layer of papers, sticky notes, and refill requests covering it. On bad days…

Coffee propels me into a higher frequency oscillation. I dart in and out of rooms and my thoughts race just fast enough not to be bothered by the sheer impossibility of the tasks on my desk, or the puzzles awaiting in each of the rooms.

Inside the rooms, and in the waiting area, people wait. 5 minutes, 90 minutes. Mostly, they’re calm. Even the kids. Sometimes they wonder what’s taking me so long.

I wonder too. I’m moving as fast as I possibly can.

Maybe I do too much. Maybe we need to set a more reasonable agenda. Each patient has waited months or years to see me, the urgency’s there. But so are the other patients.

Waiting.

A man visits me for the first time. He’s anxious, heart racing, weak, edematous. He has double vision when he looks up.

The ER did part of my job for me. They diagnosed him with hyperthyroidism and gave him some methimazole, and told him to find a doctor.

Six months ago. He’s been out of the meds for a little bit.

I grab the retired neurologist with strabismus who hangs out with the residents on Mondays. Apparently I’ve forgotten the innervation of all the eye muscles. He’s nice to me and suggests an MRI of the orbit. Graves’ disease can cause eye muscle paralysis, apparently.

 A child has headaches. Turns out she recently fled another state with her mother, because her father was beating up her mother. In the shelter there are a lot of kids who don’t always share their toys. Now she had headaches. A man with diabetes forgot to see me for 4 months and now his foot almost rotted off. We decide we need to start insulin. A patient who visits me monthly for a tapering dose of the oxycodone he takes chronically arrives with a cut over his eyebrow from a road rage fight on the way to the clinic. We sew it up. I’m already late for the next appointment, with a young woman who is “having too much unprotected sex.” I provide an emergency IUD insertion at her request.

It doesn’t stop.

A longtime patient of mine comes an hour late to her appointment. I ask her to wait until the end of the day. She does. When we finally sit down she tells me her rib might be broken, because her husband kicked her. Two weeks ago. She went to the ER at the time but waited 12 hours and finally left without being seen.

She says she’s leaving him today. We make a plan, and a follow-up appointment. She says she loves him and he’s just really suffering from schizophrenia right now. But she promises she’s going to leave.

He needs her. She may or may not need him.

She loves him. Adrenaline.

I watch her turn the corner into the hall. Now it’s my turn to wait.

Brown Rice

This morning I woke up and was instantly excited. It was time for the Quarterly All-Staff Meeting!

This is exciting in the same way as Grand Rounds might be if we had it, or the way it’s fun to eat brown rice for a change.

I was not disappointed. The morning started off with “Hooray! Lucille has worked here for 29 years! And, here are some new people we hired for medical records!” Then we learned why OSHA hates us and wants us never to eat at work. Afterward several people asked the same question in a row about whether it was okay if patients brought food to eat during their office visit.

This was followed by a 45 minute lecture about HIPPA designed to make all of us paranoid about using our smartphones, and to create passwords which no one can ever remember. In a fit of anxiety I had to tune out the guy and check my email.

Next we lined up by birthday! This is called team-building, we were told.

Then, hooray! Off to Provider Meeting.

Provider meeting is when all the doctors, CNM’s, PA’s and NP’s sit in the board room with one of the nurses who is lost, and who quickly leaves when she figures that out.  There is an agenda that is pretty accurate if you multiply each time frame by a factor of 3.

Firstly, a nice lady always comes in and tells us how we are billing wrong. This is followed by several providers giving examples of well child checks in which you also freeze off warts, asking “so how do you bill for that?” Soon enough we start worrying that the complexity of our visits are not being reflected in our billing, and someone becomes impassioned about sometimes needing to undercode for self-pay patients and someone else fights them about ethics. And throws in the word “fraud.”

Then we have to talk about access. Access is how no one can actually get in to see us but we still have lots of space because no one shows up to their appointments either. Our medical director suggests we should just take care of more things over the phone, and also that we try not to fix people’s entire lives in one visit so that the visit doesn’t take 45 minutes. Someone fights him about patients who present with chest pain, suicidal ideation and scabies all at once.

By then enough people are arguing that I raise my hand and make a feeble and vague comment intended to bring us to common ground, using keywords such as Patient-Centered Medical Home, which is mostly tangential and confusing to everyone else.

This is a perfect transition opportunity, so then we talk about how we still have no medical director after July.

Next an update on how we still don’t have an electronic medical record!

Finally it’s time to talk about productivity. We are each given a small grid detailing the average number of visits per session of the various groups of people. Everyone immediately believes the numbers are not accurate. “Well, are you keeping track of when I see a patient for carpal tunnel and then after that I put in their IUD?” “No way. I see like 15 patients a half day.” “What if the patient escapes from the clinic without turning in their papers? Because that happens a lot. Do you count them?”

Then we’re done! It’s time for Morbidity and Mortality conference! And tacos!

After all that excitement, we finally get to see some patients. Which is nice.

The Big One

???

Lately I can’t even finish a thought. That is because everyone who walks in the door has splenomegaly or a giant pelvic mass or a blood pressure of 194/105 or a hematocrit of 20%.

Sometimes I try to redirect them into familiar territory.

“Yes I know you have a giant spleen, but do you also have diabetes?”

“Your blood pressure is quite high. When was your last pap?”

But, really, those things don’t matter when you’re staring the Big Question Mark in the face.

My job is full of little question marks. “Should I check labs now or in 3 months?” “What’s the best antidepressant for this patient?” “Does this patient need a follow-up DEXA scan?”

But time stands still when I have to ask “What the hell is happening here?”

And it’s not such a great week when the Big Question Mark happens 5 times.

Put aside for a moment the technical difficulties in actually obtaining diagnostic tests in such very sick patients without insurance or any money for food. It’s hard enough to even know where to begin the work-up.

Monday started with a patient with itchy hands and feet, worse at night. No rash. Oh, and she’s also 37 weeks pregnant. I ordered some bile acids and LFT’s, and started her on ursodiol for presumed cholestasis. Then I called the Dragon, who happens to be an expert in the field. I interrupted him during tai chi. Yes, he is 85. And Chinese.

“So if this turns up positive, should I induce? She’s a VBAC.”

Then on to the next several patients. Soon I met a man with a rash all over his body for 8 years with a large, firm spleen. To be honest, I’ve never felt anything like it before. I’ve tried and failed in Africa, and confirmed its absence in kids with mono. This one was hard to miss. I percussed it too. I texted a photo of the rash to Dr. DDX. Then I got out my Washington Manual and read the section on splenomegaly. HIV. TB, mycobacterium avium. EBV. Portal hypertension. Tumor. Hemolysis. Awesome.

Then I put in 2 IUD’s.

Tuesday a lovely lady came to see me after a several year absence in which she developed worsening pelvic pain. She is 49. She has a gigantic pelvic mass.

Forgot to mention the 47 y/o cocktail waitress who presented with restless legs and turned out to have a hemoglobin of 5.7. I ended up sending her to the ER to get transfused so we can potentially get her a colonoscopy.

None of these people have insurance.

I soon found myself between patients texting my dad about splenomegaly, emailing Dr. DDX, and browsing through 3 derm atlases and a stack of charts, with 5 AAFP articles open on my desktop.

It was a bad week. I read a lot and didn’t come up with many answers. I was just busy enough not to dwell on the ridiculous inadequacy of our medical care delivery system. Not too busy to feel completely inadequate, myself, though.

But the good news is there’s time. All except for the pregnant lady, who’s been in and out of labor and delivery three times this week at my behest.  Everyone else has time. Time for me to think, and study. Time for studies to be done. Time to work on funding.

Everything seems urgent, because these are major medical unknowns. But the truth is these people have been living with these problems for a lot longer than I have. All of them for months, at least. And if all I can offer them is questions, at least I’m asking them. At least they’re here. It’s not my fault they couldn’t see a medical provider sooner. It’s not my fault they don’t have any money. It’s not really theirs either. It is what it is.

I can’t fix very much about this system. And I'm not going to know all the answers tonight. So probably I should go home before it’s time to come back again.

I added 5 stickers to my S.L.

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.

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?

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.

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.

 

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.

Week 2

This morning I’m in the hospital.  I will be here occasionally in this job.  It is large and daunting but I have found the cafeteria.  It’s not busy this morning apparently and the guy I’m supposed to follow around isn’t here yet.  In fact I may have awoken him with my 6:56am call.  There’s free wireless though so I can do facebook and pretend I’m somewhere familiar. 

Last week was remarkable for the presence of a Day Off.  This is a marvelous phenomenon which apparently exists in the real world of real doctors.  In it, you do not work on that day.  Except probably you spend the whole day unpacking boxes and go for a 4-mile run while the kids are sleeping.  But that turns out to be lovely.  And then when you go back to work the next day it is Friday and so it is only One Day Before the Weekend and you can do anything for one day.  Even if one of the patients requests you get a second opinion from a doctor who "looks older than you do."

Even if you discover in clinic that there are no ortho supplies.  Or crutches.  And you had to send a poor little girl hopping to the ER holding on to her mother’s arm.  That is unfortunate.  You can think about that on your day off.  Actually, maybe you shouldn't.  But you probably will anyway.  Hmmm.

**********

Here are some things I thought about, 10 minutes too late, today.  First impressions matter.  As you meet people while touring a hospital, probably don’t comment on people’s impressively western outfits, or tell them about your previous experiences with mentally ill nephrologists, or let them know about your fringe activities in the medical field.  Probably don’t  try to pronounce their name unless it’s John Smith.

But then I had my first delivery of the likely many to come.  One nice thing about babies is that they all come out in the same one of two ways no matter where you work.   And almost all mothers think at the last minute that they can’t do it.  And then they do.  Lovely little boy.  The thing is that in every hospital all the forms are different and the protocols are different and the delivery tables are set up differently and you’re never supposed to put the laps in the same place.  But whatever.  Babies.

Bless the babies.