Three months in

It’s been 3 months, can you believe that?

And I'm writing less. What I do is no less terrifying, maybe, nor less momentous, but it’s now routine again.

I still miss having an attending, but I don’t feel like I’m going to work completely naked anymore. Maybe like I’ve forgotten socks, or a jacket. Or my shoes don’t match one another. Maybe like there's marinara sauce on my forehead.

So that’s it then. For the rest of my life. Now it’s just the daily grind.

But wait, that can’t be right. This sounds too much like complacency. See, when I’m terrified, I at least look up everything I can. I rack my brain for the differential diagnosis and document things really well. When I’m comfortable, I think of the most likely thing and treat that, then go home and check Facebook. Not cool.

That’s not the kind of doctor I want to be. I want to be able to live with uncertainty, but strive for excellence. Advocate for my patients. Seek out the latest standard of care, question it, and meet it when it’s worthy. Solve difficult problems. Learn every single day. Be humble, but don’t back down when I know I’m right, and when it makes a difference in patient care.

I’m saying these things out loud because I’m not there yet. This kind of doctor is something between the two extremes in which I often find myself. Not just the average of the two, but something so much more. It might not be perfect every day but I won’t be happy with a goal of anything less. The extremes are unsustainable.

And that’s not all. I’m still dreaming.

Yesterday I got to assist on a c-section for the first time in 6 months. Actually, the last time in that surgery I was the one cutting. So it’s been at least 9 months since an assist. And… I still absolutely love that surgery. I wanted to be the one operating.

As soon as I feel like I’m truly comfortable in clinic, not just complacent, but competent, I’m going to kick myself in the pants and learn c-sections. I’ll do a fellowship. Then I’ll start a women’s health clinic in Africa or India and be their back-up. I’ll train midwives and nurses and help out local doctors.

Then when that gets routine I’ll move back to the states and become a politician or design an innovative new health care delivery system.

And then I’ll go on expeditions to Mt. Everest and jungly places as their doctor.

Then I’ll start a farm in order to prescribe my patients beets.

I love family medicine.

If I Couldn't Be

Sometimes I think about what I might do if I couldn’t be a doctor.  You know, were I to become incapacitated for medical work, or lose my license due to a lawsuit or clerical error by the Medical Board (not inconceivable), or were the apocalypse to be nigh, for example on Dec. 21, 2012.

Here are some ideas I’ve thought of.

·      Physics instructor

·      Actor

·      At-home parent (GB laughs at this idea, but maybe I could do it, right?)

·      Faxer of Things (see The Other Shoe Dropping 12/15/11)

·      Forest ranger

This morning as I pulled in to the hospital parking lot I realized ALL OF THESE THINGS ARE INSANELY BORING.

Obviously I would be a helicopter pilot for Life Flight (or similar.)

Probably I have never thought of this before because I have never parked directly next to a helicopter before.  It is a lovely beast.

It would be fantastic.  Not only would I be rescuing folks from remote hospitals with mediocre specialty access and possibly SAVING LIVES but more importantly I would be FLYING A HELICOPTER.

Probably I’ve never been in a helicopter before but I don’t think that matters too much.  How hard could it be?  Ask me a troubleshooting question.

What happens when there is a storm approaching?

·      Fly away from the storm.

What happens when the helicopter turns upside down?

·      Obviously you reverse the direction of the blades.

See?  Easy.

What if all the power goes out on the helicopter?

·      You should have brought your battery.  I would always bring a back-up battery.

What if there was a mutiny on board the helicopter mid-flight?

·      Obviously I would start singing Kum-Bay-Ah or a made-up song about helicopters.  Works for my kids.

What if a velociraptor appears from the sky and tackles you?

·      Consult Up-To-Date for Helicopter Pilots.  (They have that, right?)

I am so excited about my alternate career I might even see if they will allow me to ride in a helicopter one day so I can subtly talk them into letting me fly it, such that they will not even realize my pretext until it is too late.

I will grasp the steering wheel (Console? Handlebars?) with my pasty-white, overly-dry hands and conjure up reflexes and dexterity long-held dormant to guide the lovely beast safely through the air.  I will push buttons (lights?) and talk on the radio with a headset (is it called CB or CV?)  “Roger, 40, what’s your 20?  I’ll have a number 17 with Ranch Vinaigrette.  Will be landing shortly if that’s ok.  Do I land on the X or next to it?”

After we land I’ll take a moment to relax and drink some lemonade while reading a little bit about Helicopter Piloting Terminology.  Probably I’ll be considered a prodigy and earn a medal.

But first I guess I will round on a few patients.

Eve of

War Christmas

She was born this morning around five.  I walked in to meet her and examine her.  It was as if nerve gas had gone off in the room.  Three people, completely unconscious, barely arousable to a shouted “HOLA SOY DOCTORA BISON POR FAVOR PUEDO EXAMINAR A SU BEBE?”

She has curly black hair and looks like what angels might when they’re born.  Or when they spring fully formed from their father’s foreheads.  Or however angels regenerate.

She has a stork bite mark on her forehead.

She barely rouses when I uncover her to check her belly and hips.  Together we wrap her again and she goes back to sleep.

Oh, yeah, my dad is with me today.

He came to follow me on call.  We round together and discuss the cases.  I push aside the nagging worry of appearing incompetent in front of my father, and it’s really fun.  It’s also lovely to talk through the cases with someone else again.

On the way home for lunch we talk about illegal immigration.  We’re of the same mind on this one, I think.  Like, seriously, America, can’t we move on?  These are people.  Most of whom contribute to society.  Most of whom live in what used to be Mexico.  All of whom just want a better life for their children.  Just like me.  Just like you.

Mom’s not convinced.  We talk about their difficulties of the last four months. 

At home we make enchiladas.  My 22-year-old brother wants us to help him decide whether he’s a republican or a democrat.

Dad:  “How do you feel about gun control?”

Buddy:  “There should be less.”

Dad:  “Okay, then you’re a republican.”

Dad:  “How do you feel about women’s right to choose?”

Buddy: “Women shouldn’t have any rights. (ha ha snicker snicker.)”

Dad:  “Then you’re republican.”

Mom (staunch republican): “That’s not a republican value!”

Me:  “Right. He’s an Iranian.”

Later, doing dishes, Mom tells me how upset she got with my father a few months ago, how she almost thought of leaving, for good.

Really?  Mom?  I thought I was the only one who had those thoughts. Months ago now, but still. 

Is there hope for any of us?

I wrap gifts for my kids and can’t help thinking about all the overflowing heaps in dumpsters and landfills and fragments of plastic and worse that all these toys will be in just a few years.  And how so many other mothers’ children lie awake tonight, hungry, without a roof over their heads.  While my children fight over their mountains of belongings. 

But these plastic playthings will outlive any of us.  And since we’ll all die soon, does any of it matter?  The toys, the trash, the hunger? 

God, these are not very Christmassy thoughts.

My heart feels like a noiseless patient spider, sending forth filament after filament until the ductile anchor hold.  No, wait.   That’s Walt Whitman.  Actually maybe it’s just a vagrant, tired, unsettled.  Ideas and yearnings burgeoning, just about to be born, if they could only be organized.  Searching still, nightly, looking for a home.  Or maybe just a hotel room.

The family, all of them, bundle up to walk to the downtown festival of lights.  I put on my coat but drive to another home of sorts, the place where life so often begins and ends. 

Three ambulances stand between me and the back door.

Baby Guadalupe was not in a hurry.  We sat together for more than an hour before she decided to meet us.  But she was beautiful, quiet when she came, eyes wide open.  A family of 20 descended immediately upon her and her mother as I departed.  “Feliz Navidad, y que Dios le bendiga.”

So what can we offer this new innocent wonder?  What do we have to give this life?  Just fragments and plastic, war abroad and domestic disputes?  Parents too tired, from mundane struggles, to make this world a better place?  Minds full and spinning and with television and coffee and bills and weekday and weekend.  Feuding, fighting, acquiescing, quietly stewing.  Rotting, decomposing, dying.

No.  It has to be better than this.  We have to make it so. 

The cold is bitter, dark as it greets me.  My car and I speed through the night.  As I pull into the driveway I see a dawning glow. 

GB made me my own set of lights.  The luminaria glow alongside the path to our door.  I feel the heaviness lifting.

Peace. On. Earth.

Monster Hospital

Yesterday I woke up and I didn’t like my job anymore.  I had a bad feeling in my stomach as I backed out of the driveway.   Then I made an attempt to identify the factors which led to this feeling.  I outlined the following:

1)   It is 6:30am

2)   I was hanging out with the kids all weekend, leading to:

a.     Utter exhaustion

b.     Wanting to hang out with those guys even more

3)   I’m afraid of the hospital

Then I had the following self-dialogue.

“Um, you are 30 years old.  You are a doctor.  Why are you afraid of the hospital?”

“I’m a crappy doctor.”

“Why do you think you’re a crappy doctor?”

“Because that one lady was mean to me.”

“Because a lady was mean to you.  What lady?”

“Let me fill my self in.  Last time I was on call there was a lac I thought was a third degree and I’ve never repaired one and I didn’t want the patient to be incontinent for the rest of her life, so I called Her.”

“You called the patient?”

“Uh, no.  I called Her.  The OB on call.”

“Ah.  The one who told you you couldn’t do a pelvic exam.”

“Yes Her.  And She told me if I can’t repair my lacs maybe I shouldn’t deliver babies.”

“And you believed Her?”

“Yes.”

Yes, yes I did.  This is the thing about me.  I believe what other people say.  I take it seriously.  And so probably I shouldn’t be delivering babies.

That makes me sad.  Also it makes me not want to go to the hospital.  Because what else should I be able to do that I can’t?  What else should I know that I don’t? 

I’ve said I believe in family medicine, more than I believe in myself.  I believe that competence can be something other than knowing everything, being able to do it all.   Competence is listening, understanding, explaining.  Taking care of most things, and perhaps most of all, knowing when to ask for help.  Yeah, that’s what I believe.

Except on the days I don’t.

All I really want is what’s best for the patient.  Almost always I believe that they should all have family doctors who care and have a relationship with them and only very rarely need to ask for help.  Almost always I believe this will provide excellent care with better outcomes at a lower cost.

Except when I don’t. 

And when I figure, maybe I should just stay home with the kids.

I feel defeated.  And now I’m already halfway to the hospital.  I’m lame.  I don’t want to go but I’m in too deep to get out of this, so I sheepishly keep showing up to work.

But I also feel a little bit angry.

Who is She, to take away my fire?  Who is She to turn someone like me into a defeated apathetic heap?  I mean, at least I’m nice.  Also, I speak Spanish.  Also, I’m conscientious.  I’m reasonably intelligent. 

And I care, damn it.  I care about these people. 

Hundreds of folks have invested in my training.  I’ve invested years of my life.  I’ve shown up at 4am for Surgery rotation, stayed ‘til 9pm after clinic.  I’ve spent countless hours away from my kids, so many nights away from my bed.  I’ve studied about and rounded on and written notes on and talked with and sat with and broken bad news to and operated on and bargained with and delivered babies to thousands of patients all day and all night and all day again for seven years.  All because I believe.  I believe I might one day make a difference for my patients.  Who is She to stand between me and my patients?  Because that’s what She’s doing.

Because I’m letting Her.

The hospital looms like an ungainly monster.  It’s snowing hard.  I park next to the helipad and sit in the drivers seat.  The temperature plummets as I turn off the car, step outside the car. 

There’s still a little fire in my belly.  I hardly notice the chill as I run for the Emergency Room door.

The Other Shoe Dropping

Wait for it...

When I saw the schedule at first, I was glad she was coming in.  She’d be the last patient of the day.  We could figure out how her blood pressure had been, since somehow she hadn’t followed-up since a month ago when she’d been at 200/100.  We gave some clonidine in the office, then I started some meds for home. She was supposed to see me the next week but didn’t.  Then she had a stroke.

What?  Holy f*cking shit.  She had a stroke.  The scheduler wrote that in with a couple exclamation points so we would know it was important.  “Here for f/u HTN: Pt had a stroke!!” She is 49.  What the hell just happened to this 49-year-old?  How did I let this happen? 

We have a paper charting system.  We have a completely incomprehensible scheduling system that somehow involves a computer but which I have no access to.  If someone cancels an appointment no one tells me.  These are excuses, I know.  I should have put her on some kind of list so I’d remember to call her if I didn’t see her the next week.

A lot of times I’ve thought about when the other shoe might drop.  When I will blow it big-time and miss something or make a fatal error.  Back when I was a resident, hoping to get into a car accident each morning as I drove to work so I could get some rest in a hospital bed, losing my job didn’t sound so bad.  I’m sure I could find something else to do with my time.  Like, I don’t know, hang out with my kids.

Now I’m more ambivalent.  I think I actually like this crazy job and would be a little sad to let it go.  But that’s all a moot point next to the utterly sickening, kick-you-in-the-gut feeling that you’ve let someone down in a big way.  In a life-and-limb- altering way.

There were still 7 other people to talk to about their various manifestations of candidiasis before I saw her.  Obviously candida matters but it’s hard to really focus on it when obtrusive thoughts keep leaping into your brain.  “Do you have itching?” I just nearly killed someone.  “Yes.” I am going to lose my job. “I think it would be helpful to do a pelvic exam.” She can’t walk because of me.

When I walked into the room she smiled at me meekly.  Her kids were there with her.  “I am so sorry this happened to you.”  What else do you say?  Turns out she’d checked her blood pressure daily after I saw her last.  It was 130/70 or thereabouts each time.  She didn’t see the cardiologist I referred her to because her paperwork didn’t go through.  She forgot to come back to see me.  Then she had a stroke.  I asked her about drug use, about symptoms of pheochromocytoma.  No, and no.  And her blood pressure was normal the morning of the stroke.

What the hell?  This doesn’t make any sense.  Why?

I sent her home with a giant jug to collect her urine for 24 hours.  When she left I finally got my hands on the discharge summary.  Utox on admission positive for cocaine.  She admitted regular use to the neurosurgeon.  So now I’m vindicated by blow.  But she refuses to talk to me about it. 

So I’ve failed her, but in a different way than I thought.  I failed to gain her trust.  Or maybe to kick her kids out of the room so she’d give me a straight answer.  I get to keep my job.   Does she get back her left arm?

I guess we’ll have to wait and see.

You Think

This Budd's for You

Today was a late day. I did not get all my dictations done in time because I was Budd-Chiari-ing.

Budd-Chiari-ing is when your last patient in the morning comes to see you and he is young and without any medical conditions except he spontaneously developed Budd-Chiari syndrome for no reason 2 weeks ago. And they discharged him from the hospital despite ongoing fevers and no diagnosis. And now in your office he has a temperature to 103 in front of you and feels sick. But his blood cultures were negative before.

And you look on Up-to-Date for all the Causes of Portal Vein Thrombosis and check them off one by one as you determine they are unlikely, looking in the mouth for ulcers (Bechet’s disease) and palpating the testes for tumors (hypercoagulable state?) And then you look up Fever of Unknown Origin.

And then you call a bunch of specialists and stay through lunch hoping the Infectious Disease guy will call you back and the GI doctor does but he tells you a bunch of tangential anecdotes and the Heme-Onc guy doesn’t think it’s a Heme-Onc issue but gives you advice anyway that is in conflict with the GI doctor’s advice.

And it’s time to see more patients so you order some labs and arrange to speak with them by phone in the next 48 hours. And you call the ID doctor again and he ignores you.

And you think and you think and you think.

And you see some more patients.

And finally you talk to the Dinosaur. He’s got a few minutes. You sit together and look everything over one more time.

“I’d order an RF, CRP, ESR, CBC, and repeat ANA, as well as repeat blood cultures.”

Yep, that’s what I had already ordered.

“Sorry I can’t help more than that though. I really don’t know what’s going on.”

Somehow, this was reassuring. I was on the right track. And a very smart someone had no better idea what was going on than I. It shouldn’t be reassuring, but it was.

After Budd-Chiari-ing all day, one still has to complete one’s notes. So that’s what I did. I was the last one leaving the clinic. Outside, snow covered everything. It crunched underneath my feet.

Alive

Not Reading Journal Watch

I am not even going to tell you how many unread Journal Watch emails I have in my inbox. I really need to read them.

Instead I have been fashioning splints today. Today was Carpal Tunnel Day at my clinic. No folks with Carpal Tunnel Syndrome had any insurance so I made some gigantic bilateral plaster of paris splints with ace wraps for these ladies. I joked to the one lady’s son that we’d make a piñata next. You shouldn’t joke about these things with 5-year-olds.

It was a very hands-on day, in a way some days aren’t. Holding the splint in place, making small talk for 5 minutes. Sitting between the stirrups, talking a woman through an IUD insertion. Chatting to the ultrasound image of a baby’s face, just 3 weeks before she’ll be born. Measuring a penis for a concerned mother. Fundoscopic exam of a 6-year-old. Feeling the rough boundaries of a weird-looking rash. Didn’t read much at all today.

Another weird thing happened. Like 3 other providers asked me my opinion. The OB/GYN asked me a pre-operative question about hypertension and showed me an EKG. The midwife had me come in to check on a kid’s hernia. The PA with 30 years experience that I curbside all the time ran some ideas by me on a sick guy who won’t go to the hospital.

What is this? Do these people have any idea who they’re talking to? I still have to look up how to do certain joint injections. I STILL don’t know how to spell amitriptyline. Yesterday I sent someone home on accident with a recorded heart rate of 35, according to the medical assistant who took the vitals.

Yes, he was still alive. No, I didn’t notice the vitals before he left, because he was totally fine. Yes I noticed it while dictating. Yes I fell off my chair.

We called him yesterday evening and talked him through checking his own pulse. In 30 seconds he counted 13. “I feel great, doc! I don’t know what the big deal is. I’ll come in tomorrow, ok? I don’t have a ride right now.”

And I didn’t send the ambulance to his house because there was no way his heart rate was 26. But my heart rate was 120’s with frequent accels for the next 18 hours.

He sauntered in over lunch break today. I put him in a room myself and put my hands on his right radial artery. Pulse 88. I placed the blood pressure cuff over his upper arm, and inflated it manually. 140/80.

Still alive.