August 22, 2014

evermore

     My breaths are coming in gulps as I feel my heart racing.  I know what this is but intellectually that doesn't make it any easier.  Fight or flight.  Only there is no tangible beast from which to flee or stand my ground and fight.  These are beasts of the mind.  Three years of dealing with existential blow after blow after blow and not a single panic attack.  Why the hell are they coming now?  Why does the sun rise in the east might be an easier question.
     The basic medical model of treating these is that one is under too much stress.  No shit.  Since my life experiences are not about to fade into the background anytime soon, the medical model pretty much starts and ends right there for me.  Step back into history a bit before we had good medications, and there are relevant theories about psychological disturbances.  Carl Jung focused on the imagery surrounding the experience and sought to learn from the disturbance.

Jung: What was the most distressful feeling during the experience?
Me:  Feeling like I could not breathe.  With each inward breath, the tightness of my chest would not let it in.
Jung:  So you had trouble inspiring?
Me:  Yes.  It took an effort of force to drive the breath in.  The expirations were short and quick.  But the inspirations were long and labored.
Jung:  I can't do it all for you......
Me:  Ah.  Inspiration.  Or, lack thereof.  So I'm back to Hamlet, again, am I?  Slings and arrows, take up arms, cast off these mortal coils.  I thought I'd moved past that.
Jung:  Apparently not.  That, or there are new slings and arrows.  Since you're not listening to your subconscious, consider the panic attack a not so gentle tapping on your door from your psyche.  You would do well to open the door as the next sound of some one gently rapping, rapping at your chamber door may not be so gentle.

August 15, 2014

what if?

The following is not FACTUALLY accurate. Details have been changed, things deleted, stuff made up, all to protect identity. But it is 100% absolutely true.

     "How are you feeling this morning Mrs. Smith?"  It was my first day on the ICU ward and as with any first day of a rotation, I tend to keep things low key until I get a feel for the way the team functions.  In this case that means the respiratory therapists, the nurses, the new interns who just started practicing being a doctor for a week now, upper level residents, a fellow, and an attending.  It's a large milieu to insert a med student into.
     "You tell me doc," she responded as she was currently passing foamy diarrhea while the nurses cleaned her up.  The nurse looked at me and with her eyes and asked, "you ever seen anything like this before?"  I must confess I had not.  But I did my physical exam and when rounds came I presented the history and the pertinent physical findings, especially a distended abdomen which had not been noted in the chart.  In my plan, though, I stopped short of recommending an abdominal CT.  I thought she definitely needed one but I didn't speak up.  I've been so bruised and battered and broken these last years, I didn't feel like rocking a boat on the very first day.
     I came in the next morning at 0:dark 30.  My patient's room was empty.  Maybe she got transferred and so I picked up another patient.  It wasn't until rounds that I learned that  overnight Mrs. Smith had coded multiple times and died, likely of a gastrointestinal infarct.  An autopsy was scheduled.  My heart sank.  After rounds I went up to the attending and asked why she never received an abdominal CT.  No one knew that she had a distended abdomen.  I said it at rounds.  Loud and clear.  My voice projects as I am no wallflower.  But I never said, "she NEEDS a CT."  Tell anyone this story and clearly it is not the fault of a med student.  There was an intern, an upper level resident, a fellow, and an attending.  And even if she had the CT done, it does not mean she would have survived.  The patient was in the ICU for multiple reasons and when multiple things start to head south, there's not a lot we can do.  But the question, "what if?" hangs in my mind, especially given my past experiences.  I do not allow myself to miss things despite rationally knowing that's impossible.  No one can bat a thousand.  But still, what if?  Would Mrs. Smith still be alive?
 

August 8, 2014

a shift

The following is not FACTUALLY accurate. Details have been changed, things deleted, stuff made up, all to protect identity. But it is 100% absolutely true.

     With every physical, there is a 12-point Review of Systems.  In order to get paid, you must include at least 12 systems.  11 and you don't get paid, and with good reason.  One of those systems in Psych.  This particular patient was smiling and answering no to all of the other systems, even the one involving chronic muscle or joint point.  Usually that gets most people over the age of 40.  Everybody has some ache or former injury that causes some discomfort.  But not this one.  It wasn't until the psych questions came that a pregnant pause occurred.  It was not their psyche that was the cause of concern.  It was one of the children.  They had begun to have their first psychotic break.  The parents never saw it coming. 
     My heart began to break and I had a choice.  Do I begin to connect those rooms with corridors?  Do I let my own pain help others?  But how do you do that without making it about you?  Then I heard what the medications were being used.  The prescribing physician was either 80 years old and hadn't read a new journal in over 40 years, or a complete and lazy asshole who just wanted to snow the kid.  In other words, turn them into a stupefied zombie so they're not causing any trouble.  They're also hardly conscious.  My decision flew out the window.  None of that crap seemed to matter anymore.  Without even thinking, I began, "In my personal experience......"
     I encouraged the patient to stick with the child.  They will need someone steady.  I warned them at the first onset of mental illness, it can take upwards of a full year to get the right diagnosis and more importantly, the right combination of medications that works well for them.  I warned them this will NOT be easy.  I warned it may take multiple opinions to get to that right combination of medications.  And then I again reassured them to take heart, to not give up, to love your child.  And before I even realized it, I said this all in front of the attending.  I had never done such a thing before.  They did not correct me or interrupt me.  Instead, after exiting the room, he asked about my son in a heartfelt way.  As I said in my last post, something is shifting.

August 3, 2014

unfortunately

     It was a blur, this last month.  A feeling of something important moving from inwards to outwards.  A house with multiple rooms, each room appropriated for its own feelings and thoughts.  Depersonalization.  From the moment the alarm goes off until I stepped into the clinic, one part of me was being turned off, compartmentalized, while another turned on.  Then, the reverse would occur at the end of the day.  There must be some way to integrate these rooms, or at least connect them with corridors.  There is only so long one can function as a whole when functioning as separate parts.
     At the end of the month, I am left with a glowing evaluation and it means absolutely nothing to me.  When questioning the attending, I was strongly advised by the assistant to preface it with, "We were taught xyx...." 
     My response, "Bullshit.  I'm too old and have seen too much to play that nonsense.  I'm not some 20 something kid still wet behind their ears."
     With each passing day, I care less and less what others may or may not think of me.  I am not here to impress upon anyone some false notion of what I am or to stroke someone's ego.  What matters most to me of the past month were the words that did not go into the evaluation.  The attending told me, "unfortunately, you have a level of empathy with patients that very few will ever have." 
     With the exception of that first word, I have been told this multiple times by multiple attendings, family members, colleagues, and even therapists.  Others have called it a gift.  I despise that with every fiber of my being.  I want to strike back with physical force at those who dare call such pain a gift.  Without hesitation I would trade all my wounds to be a mediocre doctor and have those I love back.  But this attending added that one word.  Unfortunately.  It allowed for all of the pain and suffering to be honored while allowing something soulful to emerge.  One does not take away the other.  Unfortunately.  All the pain and agony of my brother's death.  Unfortunately.  Those decisions I made at 3 am with no one else to ask.  Unfortunately.  The last year battling with my son's illness.  Unfortunately.  All the continuing struggles with my son.  Unfortunately.  And my dad?  He was in the ER less than a month ago.  Unfortunately.  He'll try to downplay it in his blog but he forgot to mention that he had an elevated white count of 20,000.  Not something you want to see in a stem cell transplant patient.  Unfortunately.

July 13, 2014

cell phone

Having just upgraded to an iPhone 5 courtesy of my sister-in-law, this comment below is quite amusing, and very disturbing. My iPhone is a combination of a beautiful design and intuitive functionality that makes my life more productive. The EMR I use everyday leaves me cussing. So read this interesting analogy from a comment on KevinMD.com regarding an article about Electronic Medical Records, aka another requirement by the "Affordable" Care Act which is anything but affordable.

The year is 1990. The federal government has made the decision that everyone needs to switch to cell phones. The government claims that landlines are too inefficient and prone to error which may or may not be true. The only thing everyone can agree upon is that it is much easier for the government to monitor cell phones then landlines. In order to coerce people to switch to cell phones the government first provides bribes, but eventually will fine people for not making the switch. However, in order to get the bribe the users have to follow and document certain guidelines and have to do so within a fixed time frame. 
Cell phone carriers rush in provide the phones. With the rush to make the switch, fundamental errors are made such as different carriers working on different frequencies so some phones won't communicate with each other, if you can get a signal at all. Worse still, the market is dictated not by what the users may want or need, but how best to meet the criteria to get the bribe. Phones are made with a 25 digit keyboard so required codes can be entered. Before each call can be made a pop-up question screen appears so that the user can meet the requirements the government has decided are necessary to make the call. 24 years later some users have gone through multiple phones, cursing the day they ever switched from landlines.

July 4, 2014

knocking the rust off

     I look at my text.  There's a patient in the ER who has Pick's Disease.  Pick's Disease is a form of dementia a bit like Alzheimer's except instead of memory loss being the major first symptom, they tend to have personality changes first.  What used to be a prim and proper little old lady will start cussing like a sailor and then not see that they've changed or done anything improper.  Like any dementia, it tends to be hardest on the family members and caregivers.  The spouse had reached their limits and could no longer protect the patient from their self so came to the ER.
     There was nothing I could for them medically.  But being a doctor is more than just being a drug monkey.  I did what their neurologist should've had the guts to do but didn't.  I started to have "the talk" with them.  What does the patient want from their last moments on this earth?  What does each of the family member want?  How can it be arranged that the patient is safe but their final wishes still be honored?  I didn't intend to complete the conversation then and there.  I just wanted to plant the seed and begin to allow the questions be pondered and pontificated over.  They still had time to do that.  But I told them they don't want to have that conversation when the patient gets admitted for pneumonia and the next thing you know, they're in the ICU and everyone is too stunned to know what to do next. 
     Before this June rotation, it had been a good 10 months before I had seen an adult patient.  There was a lot of rust to knock off.  And even then, there wasn't the rhythm and flow that I used to have for the first 9/10 of the rotation.  This patient was the first time I got back into that groove.  I heard their story beyond just the physical problems and connected with them.  The fact that it was on a terminal patient is not lost on me. 

































July 2, 2014

fail

     "Failed?  What do you mean 'failed'?" my wife asked puzzled.  "You never fail."

     But indeed I had.  A clinical exam, no less.  In my defense, it had been 10 months since I'd seen an adult patient and had more than my share of problems on my mind.  But I've been operating that way for years now.  Why did the cracks start to show now?  That's really not quite true.  The cracks have been there all along.  And quite a few more have been added along the way.  It would be akin to breaking my leg in the backcountry.  How far could I hike on it before the broken bone becomes too much?  How long can willpower and adrenaline alone last?  At some point, healing must begin to take place, even if in the most minute spots.

     I passed it on the second try.