January 25, 2013

something to look forward to

     Somewhere along the line during our frantic training, we're supposed to figure out what we want to be when we grow up.  Some students come into school with that already decided.  They're usually the surgery type.  Others figure it out during the first two years.  But most don't know until the third year.  That's when we start rotating through all the major divisions of medicine.  I had some ideas about what were important to me and accordingly some fields fell onto My List of Considerations. 
  1. Family Medicine
  2. Internal Medicine
  3. Ob-Gyn
  4. Oncology
  5. Emergency Medicine
     Each had their appeal and their detractions.  ER was a rush but that could also mean burn out.  Ob-gyn got to see the start of life with all the hope and promise but the hours flat out suck.  Oncology, well, I don't need to elaborate on that one if you've read me at all.  Family vs Internal medicine both involve some similarities and was a source of conflict in deciding.  I wanted to see how they worked in real life before I decided.  The day to day grind meant as much to me as the type of patients or diseases. 
     I did not expect help from my son in figuring out what specialty was going to appeal to me.  See, he recently turned 16 and we were hemming and hawing about what kind of vehicle to get him.  As fate would have it, a jeep for sale was out front of the small hole-in-the-wall restaraunt that I've been frequenting for over a decade.  I used to have a jeep.  Had to sell it when my wife was pregnant with said son.  Something about a car seat not being safe in a rag top jeep without doors.  She had a point.  So I didn't need much convincing to get me, I mean my son a jeep.  So along with some help from his grandma, we got this.
     I'm not sure who loves it more - me or him.  My wife keeps reminding me, it's not mine (although the name on the title begs to differ).  And so what does this Zombie Outbreak Response Vehicle have to do with my selecting a field of medicine???  It's helped solidify an idea that's bouncing around in between the cobwebs of my head.  Rural medicine.  Smaller town doc who does a little bit of everything, and I mean everything since there are fewer specialists out where one can breathe.  The doc who actually knows his patients.  Who knows and treats generations of the patients.  And a doc who lives on some land where he can't see his damned neighbors because they're too far off in the distance.  Maybe a bit overly romantic, but this jeep has kindled something that was already there.  Aside from that, I feel like it's pulling me out of a deep, deep pool of shit which is where my life has been these past few years.  Did I mention the jeep has a 12,000 pound winch on it?  Good thing, too, as you can see below.  Everyone's life needs one of these to pull one's psyche out of the depths of hell and give it something to look forward to.


January 18, 2013

wish them well

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.
Spirits turned bitter by the poison of envy
Always angry and dissatisfied
Even the lost ones, the frightened and mean ones
Even the ones with a devil inside

Thank your stars you're not that way
Turn your back and walk away
Don't even pause and ask them why
Turn around and say goodbye

People who judge without a measure of mercy
All the victims who will never learn
Even the lost ones, you can only give up on
Even the ones who make you burn

Even though you're going through hell
Just keep on going
Let the demons dwell
Just wish them well
"wish them well" by n. peart

     Admitted on a Monday night while I was on call, she was gone by the end of the week.  She left AMA (against medical advice).  She was fed up with her bipolar nature, with the staff, with the hospital, with her life.  She had tried every medication and every street drug and nothing helped.  Her previous suicide attempt had been halted only by a rather miraculous medical intervention. We spoke with the mother over the phone. Unable to listen, the patient stormed out in a fit of rage after only a few minutes. The mother continued her story for a good half an hour.  She corroborated everything the daughter said, even adding details the daughter didn’t get to. This one was not faking, not exagerating, not just a drug seeker. The mother told us:
Look, I appreciate everything you’ve tried, I really do, but you have to realize that she’s been worked up countless times.  She had an extensive psych and neuro workup – everything – at multiple institutions and they couldn’t do anything to help her.  She’s been to so many doctors and nothing. Everything we've tried....nothing. We’ve given her places to live and she’s destroyed them. I’m still paying off the damages at her last place. She's my daughter and I lover her dearly and I know this sounds cold and heartless, but I’m surprised she’s still alive.

     Many of the staff hated the patient.  Her raging temper was set off by saying the wrong thing, even by a wrong look.  And she herself hated it.  She hated herself for not being able to stop it.  You could see her speech begin to speed up fasterfasterfaster as her lips struggled to keep up with her racing thoughts.  She wanted it to stop.  She said so but then two minutes later she was cussing someone out.  There's a fine line sometimes between distinguishing an asshole from someone with mental illness. There was no doubt in my mind she belonged to the latter.  Nor the doc who sadly but realistically doubted this patient would survive the year. 

    And yet the patient had never raised her voice at me.  She never got angry with me.  She never threatened me. The attending, exasperated, finally relegated the patient to me since she seemed not to be able to talk to anyone else without becoming frankly violent. To be honest, I’m not sure why I was able to talk to her. When it comes down to it, I think I saw my son there. My wife’s family has mental illness running in its past and I thought to myself, “if my son had been born into that situation, this could be him.” It scared me tremendously to know that the genetic possibility was there. So I talked to the patient as if she were my own son. But that wasn't enough.

​      Before the patient left, I went to say goodbye to her. I told her, “I wish you well." It's all that I had left to give.

     And that’s the part that bothers me the most. The patient was cognizant enough to know that she needed help.  She knew that she was headed for a bad ending. Her entire being was unraveling. But she was powerless to stop it. And so were we. We had nothing in our bag of tricks to help. Was she too broken for us to fix? Was there ever even a point in her life that interventions could have changed her path? Had the medical system failed her by not being able to permanently institutionalize him? Was she just a bad person who continued to choose drugs over treatment? Was she just trying to manipulate me?

     She’s the one that got away. The patient that I couldn’t treat. But more than that, she was a broken human being that could not be helped. We are taught never to give up. To never quit on a patient. But that doesn’t work in real life. Tragedies do happen. Horrible things do occur. I learned that first hand from my brother. And we as doctors, as human beings, are all too often unable to do anything about. In that regards, serious mental illness is no different than cancer, than heart disease, than HIV. They all tragically take human life.  Her life was indeed tragic and his story will stick with me always.

January 15, 2013


    Call.  It's a four-letter word to me, both literally and figuratively.  Might as well spell it c@ll as it represents a bad, bad thing to me.  I think the person who invented call must've been deprived as a kid.  Not enough sleep overs.  What else would possess a person to force his colleagues to spend the night dressing up in pajamas (scrubs really are glorified pajamas), eating cold pizza at two in the morning, and staying up aaalllll night.  I mean, how could that not be fun?  Did I mention making decisions about people's lives while not having slept in 28 hours?  What could possibly not be awesome about that?

January 11, 2013


     "The man who drew my blood looked like they dragged him off the street.  And the one who changed my bandages?  WELL, she might as well have been homeless!  I can't believe such things would go on at such a prestigous facility," the patient said with a huff of indignation.

     Needless to say, none of what the patient claimed actually happened.  But they sincerely believed that it did.  In reality, this is what often happens when you operate on a 63 or a 73 or an 83 year old patient.  They go through the physiological and pscyhological stress of the surgery, of the anesthesia, of the painkillers and as a consequence, they often become delirious.  It has nothing to do with the person being crazy or unstable.  It happens to the most stolid of patients.  Monkeys crawling on the ceiling, garbage men masquerading as nurses, other dimensions on the other sides of mirrors.  All these and more come out after surgery, usually getting worse in the evening earning this condition the nickname of "sundowning". 

     It especially is bad if a particularly unenlightened surgeon leaves benadryl or ativan for the patient.  Those drugs don't do so well in the patient age range north of 65.  Makes them much worse, actually.  Sadly, too many surgeons don't know this.  Vitamin H (haldol) or Seroquel become wonder drugs in these situations.  Know what else helps?  Family members.  They seem to be the most grounding and orientating of medications.  Seroquel calms them down and the family member keeps them from wandering out of their rooms and out of their minds.  So the next time you have an elderly family member in for surgery tell you, "don't bother coming up to the hospital. I'm just going to be sleeping of the anesthesia," don't listen to them.  Doctor's orders.  Your presence keeps them sane and out of 4-point restraints which keeps the nurses and the on call doctors sane.

January 3, 2013

REAL fear

"You do NOT know what it's like." I heard this from my brother on occasion. And he was right. I didn't know what it was like to be the one facing death by cancer. But I got one small taste of it recently. And if it's but a fraction of the existential angst he suffered, I shudder at the very nature of it. You see, I have had worsening back pain over the last six months. Big deal. Lots of guys get back pain. But my immediate family is two for two in going to the doctor with back pain and coming out with cancer. There's a saying in medicine that says, "when you hear hoof beats, think horse, not zebra." It means common things are common. Do not go looking for bizarre diagnoses when common ones will suffice. But, as one doctor so aptly told me, what do you do when your family history IS a herd of zebras?

My mom and dad strongly encouraged me to get it looked at. My wife could not bring herself to even contemplate the grim possibility. And I thought, "if there's back pain then that means a metastasis. Frankly, I'd rather not know at that point and live out as many days in blissful ignorance as possible."

But I broke down and got an MRI for various reasons. Some to assuage my family. Some to try to pragmatically solve my pain problem. But mostly to confront in my mind the very real possibility of what may lie there. Anticipating the anxiety associated with claustrophobic spaces, I decided to opt for an Ativan. It wasn't enough. I explained to the MRI tech that I hated small spaces so he was very humane in his treatment of me, talking me through each scan and letting me know the progress. I had one more scan to go, about five minutes, he reassured me, so I took deep breaths, closed my eyes and listened to the hypnotic clicks and clangs of the magnet. The voice of the tech came over the intercom at the end of the last scan, "I need to run an extra scan."

My heart sank immediately. What did he see that necessitated an extra scan? Mass? Tumor? What kind of tumor? My life did not flash before my eyes but I did spend the next five minutes with my thoughts rushing endlessly. What do I tell my son? What will happen to my wife? And my parents? Do I even bother with treatment? What last thing do I want to do before dying? Do I even bother to keep up with my training? How do I keep from experiencing the excruciating physical pain that my brother did? It was the longest five minutes of my life and for that brief moment, I had the smallest of inkling of what my brother must've wrestled with daily. I would not wish it on anyone.

When the tech came in, I asked him flat out why he ran that scan. "Why did you run the extra scan? Were there any mass lesions?"

"No, nothing like that. But how many lumbar vertebrae do you have?" Apparently, I have an extra lumbar vertebra. Normal people have five and I have six. I've never been so relieved or happy to be congenitally abnormal because it meant no tumors. Because of the holidays, I had to wait a good three weeks for the official radiologist report to find out for sure that not only do I have an extra lumbar vertebra, but also an extra thoracic one in addition to only 11 ribs on one side. Either I donated a rib to make Eve, or my parents are brother and sister. Add some degenerative disk disease and I have some very painful and yet happy causes of back pain.


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.

     Not many patients scare me. Even though I was used as a human shield placed between the patient and the doc, there were not many times that I felt to be in danger. Jose, however, scared me. Schizoaffective with mania. That meant poor Jose was both schizophrenic AND manic. Nothing like taking someone who hears voices commanding him to do things and adding mania to the mix. So long as you did not say anything bad about Kelly Clarkson (they were lovers and he had special powers to talk her telepathically) he usually could be calmed back down after he got worked up.

     When I first met him, he worry baggy clothes which hid his frame. Shorter than me, I wasn't too alarmed by him, despite his ability to get worked up very quickly. After all, I didn't have to be able to fight a patient. I just had to be able to keep them off the doc long enough in order for a tech to rush in and get a shot of Vitamin H into them (that's haldol). I first became a bit concerned when Jose commented that he liked to work out. He rolled his sleeves back to reveal biceps the size of softballs. Yikes. I became slightly concerned the day we brought him into the room to talk. I left the door cracked. Deliberately. As in leaving an escape route. The patient ever so politely got up to close the door. Now he was caged.

     I really became concerned when the doc decided he wasn't stable enough to be released. Uh-oh. Wait. He didn't understand. The doc had a thick accent. Leaning over to me, the doc asked if I could explain to Jose that we needed to keep him longer. Ummm, seriously? I don't think this is quite the role of a med student but sure, why not? Taking a deep breath I calmly and in as non threatening a voice as I could muster, I explained it to the patient. He clearly understood me because the chair got overturned as he leapt to his feet. Tense as a wound spring, his arms flung around in agitation as confused and angry threats flew from his mouth.

    Long term problem was how to manage this patient's labile mood. Immediate problem was how to avoid a scene from Fight Club. I'm not quite sure how I got the door opened and the patient out of the room without getting hit. I kinda flashed back to my wildlife days when I once came face to face with a rogue Cape buffalo. About the same level of adrenaline only no chance of getting gored. But fortunately, no harm came to him or me.  Unfortunately, the doc found that I was able to handle the wild ones and was thereby cursed to deal with all dangerous ones.