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?

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.”

While I'm At It...

Another dream:

Everyone else is in EMR (electronic medical record) training. It’s super awesome and there’s a pic in the staff newsletter of everyone jumping in the air with joy. I, instead, have to see patients outside next to a kiva fireplace near a pumpkin patch. All my patients have fibromyalgia. For lunch I have barely enough time to look for food, and all I can find is a small piece of stale bread.

WTF, brain?

Dreamy

Last night I was on call with a resident. She told me she had a dream in which she was evaluating a woman in OB triage when all of a sudden the patient’s baby came out without any warning.

Here is the sort of dream I have.

I am running through a maze of doors, under a dark sky with trees. Several rabid deer are chasing me. The doors are crumbling, so when I close them behind me the deer can still get through. Finally, a room seems safe, and there is a piñata. I stand next to it and it breaks open and millions of tiny chainsaws fall out.

The good news is neither of those things happened last night.

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.