I'm on a boat

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“You’re on a lifeboat. You only have so much space. Are you going to pull in the ones who are waving their hands at you, calling for help? Or the ones who are swimming away from you?”

Huh.

The communist PA and I look after each others’ patients sometimes. While I was away he saw Yellow Eyes. Who, while not wanting to die, is still drinking himself to death. His legs and belly have grown. We have to see him once or twice a week these days. The story is always the same.

“Yeah, I’m still drinking, but I’ve cut back, a LOT.”

“I don’t drink hard liquor anymore.”

“You know, no one quits unless they are ready. You have to want to,” he tells me.

And I want, so badly, for this to work out for him. But he’s drowning. Can’t really breathe. I don’t think there’s water in his lungs, but the twins-gestation-sized belly he’s grown doesn’t leave a lot of room for the air in the top half of the torso.

The communist asks me about him. I admit I don’t know what else I can do. In fact, I’m not really doing anything, just adding water pills and running out of time.

So he gives me this cryptic advice about boats.

I used to be a lifeguard. (Now the card is expired. I can’t use my CME money to renew it. Apparently.)  Anyway, in training we learned that people who are drowning will grab hold of a rescuer and push you under. Nothing you can do, it’s just their instinct to survive. And you shouldn’t fight it, just go down, away, then up. But in practice, you should try not to let it get to that point. So, always carry that floaty thing, and put it between the drowner and yourself.

168 pounds, Yellow used to weigh, when we first met. Last month he crept up to 180. Now he’s 210, 212, 214. Taking his meds only when it rains or something. Definitely not as directed.

I call a few days after our visit for an update. His daughter tells me he’s in the hospital. They took the water off and he’s decided to detox. That’s good.  Early the next morning I was there to deliver a baby, then stopped by his room after. His belly looked a little more post-partum than gestating. He was, as ever, full of smiles.

“I think I’m really going to do it this time, doc. No drink for 5 days, now. The priest came by.”

And I want to believe it, I really do. But I’m not going to paddle after him.

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.

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.

Intake

Based on several new patient encounters over the last few weeks, I’m making an intake form for all new patients requesting narcotics.  It will look something like this:

1.   Are you taking cocaine right now?

2.   No? Good. Okay.

3.   Why have you fired your last 3 doctors or been fired from their practice?

4.   Are you expecting narcotics today, as in, right now?

5.   Because I am not going to give them to you without a little more information.

6.   What exactly is your pain?

7.   What, besides Vicodin, are you doing for your pain?

8.   Ok, what, besides medications, are you doing for your pain?

9.   Are you taking methamphetamine right now?

10. No? Good. Okay.

11. Are you willing to submit to a drug test?

12. Why aren’t you able to pee today?

13. If you had to choose among the Percocet, the Xanax, and the Soma you currently want to take all at once, which would you pick?

14a. Is it cool if I call your previous doctor before our next visit?

14b. Please list the names of the doctors you have received prescriptions from in the last 2 months:

1)_________________________

2)_________________________

3)_________________________

4)_________________________

5)_________________________

6)_________________________

15. Many people seem to have nicknames for their medications. What do you like to call your pain pills? (e.g. oxies, vikes, etc.)

16. After leaving jail last month and having been off narcotics for a year, why did you then immediately resume taking 8 oxycodone 30’s a day? Are you sure you’re taking them? Because you do not appear to be dead.

17. In the past month, how many times has your cat knocked your Vicodin into the toilet? (0-5) (5-10) (>10)

18. In the past month, how many times has your cat knocked your Ciprofloxacin into the toilet? (For statistical purposes only)

It will be printed on pleasing pink paper with a marbled background and smell like candy canes.  I’m super excited.

When I Hate My Job

Potter

“He looks like he’s ready to go to the disco,” K said, impressed. It’s been a while (never) since I went to a disco, but I had to agree. Wide collar, sparkly shirt, perfect hair.

Attentive, focused, by his wife’s side. It won’t be long now.

She’s a day shy of 35 weeks, but her body decided to have the baby today. I don’t have records, because it is the weekend and apparently we live in medieval times. Or 1975. It’s never really clear in the middle of the night.

She says it was a normal pregnancy, and she seems like she knows.

To be safe, I checked with Swiss. Sometimes we have these folks deliver in the city. She thinks we can manage here tonight, and she’ll be there.

It takes a while but it’s her first baby. An epidural helps her relax. Finally it’s time to push. Slowly the baby’s head comes down. Slower than I’d expect. An hour and a half into the pushing we’re getting close. She is quiet, focused. He is always by her side.

Swiss comes into the room, checks the warmer. We’re ready.

The baby’s head delivers. But then he’s stuck. I apply extra pressure. K and another nurse pull back her legs and help roll the shoulder forward from above the pubic bone.

Except the shoulder is already under. I can see both shoulders, they’re out. But baby still won’t come.

I don’t get it. This is not in any book. All the maneuvers I ever learned had to do with getting the shoulders out, but they’re out, and the baby’s still stuck. What is stuck? Is there another kid in there? An omphalocele?

Swiss is watching me.

I bring the head anteriorally. No movement. I try some sort of Wood’s screw, if you can call it that with the shoulders already out. I think about cutting an episiotomy. Finally I loop a finger under each armpit and slowly and firmly pull out. There’s belly, belly, and more belly.

The child is before me. A huge abdomen, 40cm in circumference, floppy. Little flipper feet. Tiny chest. Blue. No tone.

Swiss freaks out. I hand her the child as quickly as I can cut the cord. She starts to resuscitate, then moves the whole operation out to the nursery.

It’s quiet again, panic in their faces now.

I have no idea what just happened. I tell them it looks like their baby was born with some problems.

They’re terrified, and want to know what is happening. I duck into the nursery, where about 18 people are trying to intubate the child. A neocode has been called.

I go back in and tell them what I know.

The next six hours I split between their bedside and the unfolding drama. More of “We’re not sure what this means, but this is what is happening and here is the plan.” Transport arrives but hangs out for a couple hours with Swiss to stabilize. More tubes, lines, xrays, consults, taps, needle thoracostomies. The lungs are too tiny. The belly too big. There’s a mass near the bladder and the kidneys are huge, maybe cystic? The oxygen is lower than expected.

Finally he’s ready to go to the city. I bring them over to see their son for the first real moments. I have to give them permission to touch him; the lines and tubes have a way of keeping folks away. A few minutes of the three of them, and then he has to go.

The next morning, at the University, he codes again. This time, he doesn’t make it.

They were on their way. But the first time they were able to hold him, he was already gone.

And why? Well, it was the Potter sequence, you see. He had posterior urethral valves, meaning the urine couldn’t leave the bladder and backed up. The pressure got high enough to blow a hole in a kidney, filling his abdomen with urine. Meanwhile, over weeks, he made virtually no pee, so the amniotic fluid was chronically low. Thus his legs never developed fully, and, more importantly, neither did his lungs. He died because he was born 5 weeks early with lungs that were 15 weeks early.

Yes. I understand. But why?

Yes, and

I think in possibilities. I like to think that’s a strength. When a 59 year old has a spot in his vision I can think of all the possible reasons why and test most of them.

And still ultimately refer to ophthalmology.

When you’ve got belly pain we can come up with the 14 most likely scenarios and check them off one by one. Never fear that you will leave my office with the dreaded diagnosis “Belly Pain NOS.”

(Because at the very least you will have been diagnosed with “Abdominal pain – poorly characterized, which seems unlikely to be fulminating hepatitis or acute abdomen, and all the labs are normal and whatnot, and nothing about it sounds remotely like the gallbladder or kidneys or liver or pancreas or any known intraabdominal entity, but what the hell is it? Could it be gas? Anticipatory guidance for infinitesimally small possibility of catastrophic pathology in early developing stages given.)

It’s something I learned from my college Improv team. When you’re under the gun (performing in front of hundreds of bored college students vs. 1 terrified patient) and something is suggested, you roll with it.

Example from Improv:

Player 1: How nice we’ve gone out to sea on this raft!

Player 2: Yes. And I can’t believe we’ve fit a dinosaur on board as well.

= interesting. We all know where we are and hope we don’t sink.

Example of what not do to in Improv:

Player 1: Here we are buying carpets in Turkey.

Player 2: No. You fucking idiot. This is a night club and we are DJ’s. Is that caviar or boba?

= confusing. Where the hell are we? Also player 1 is an idiot, but player 2 is a jackass.

In Improv you never say No. You say “Yes, and.” It’s an exercise we do to warm up, and it’s a philosophy we live by onstage.

Thus, I have a really hard time with no.

Examples from more or less the last week in the Improv of my life:

Patient: I have a sore throat. Last time I had a sore throat it was immediately bettered by penicillin from Mexico. Please prescribe me penicillin from Mexico.

Me: Yes, and actually you have a viral syndrome and I don’t believe you need penicillin at all. I will now explain to you supportive measures for 10 minutes and hope you believe me.

Patient: I don’t understand.

Patient: I have pain in my arm. I need an MRI.

Me: Yes, and it turns out you have pain in your arm. And it turns out you have lateral epicondylitis which is tennis elbow and let’s all laugh together because you don’t play tennis. And it is not diagnosed by MRI but rather by me pulling on your wrist like so and you shouting in pain as you have just demonstrated.

Patient: I don’t understand.

Me: Shall I offer you a brace?

Patient: I fell over. I need an MRI so I can be cleared to go back to work.

Me: Yes, and. Wait. I don’t understand.

Patient: I have seasonal allergies. I need to see a specialist.

Me: Yes, and what if first we try some allergy medicine while we hope to recruit an allergy specialist to this county.

Patient: My back hurts. Generally I take 50 Lortab a day to stave off the pain and so please give me some.

Me: Yes and how about instead we discuss non-pharmaceutical measures we might take for chronic back pain. Here is a list of 15 other ideas we could consider.

Patient: No. I tried all of those.

Me: Yes and also you were taking cocaine the last time I saw you and so we will be avoiding the narcotic class of medications in the future.

Patient: I don’t understand. Give me Lortab please.

Me: Yes and actually I will not.

Patient: I was not taking cocaine myself, but unwittingly did visit my sister, who was smoking crack, immediately prior to my office visit that day.

Me: Yes and how is that related to our discussion?
Patient: Obviously I must have inhaled it from the room and so that is not my fault and please give me Lortab.

Me: Yes and it is unfortunate that as far as I know that is physiologically impossible.

Patient: Lortab.

Me: Yes and

Patient:?

Me: And no. (Dammit. No. What I mean to say is no. I cannot, will not give you Lortab. I could lose my license. It is not what you need. You have a problem. You need help. We have policies.) (I don’t actually say most of the portion in parentheses)

Patient: I don’t understand

Me: Yes and shall I print you a handout? I’ll be right back…

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.

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.

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.

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.

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.