December 28, 2015

the beginning of rehab



When I got out of the hospital, I could barely walk 20 feet. I began rehabbing by hobbling around with a cane in the gym the day after I got out of the hospital. (Caveat, this is NOT an exercise I recommend. There are better.)

December 25, 2015

Christmas in the call room



Not a pager was stirring. Nor even a phone. 

you can never break the chains



I pronounced the patient's death and eventually made my way to the hospital chapel followed by the ghosts and demons of my past. Some stories are too private, too difficult, too complex to put into words. Perhaps they are best illustrated by the mosaic randomness of a backlighted piece of stain glass in an empty, dark chapel.

December 19, 2015

pain scale


It is my day "off" and I'm back in the ER. The abscess has started trying to grow back. I'm lying in the uncomfortable bed and notice the Visual Analog Pain Scale on the wall. I hate this thing. It's utterly useless both as a physician and as a patient. I much prefer this scale. 

December 11, 2015

and the bottom is reached




Its 3 am and I'm in the hospital. The slow, rhythmic whir and click of the pump is somewhat of a comfort to me. It takes me back to when I was stronger. When I was there with my brother and dad. It's not nearly as impressive as my dad's or brother's IV pole which had two rows of pumps and countless bags. But when the doc pulled out Zosyn, I knew I was much, much sicker than I realized. I only saw Zosyn being used in the ICU and at MD Anderson. 

December 6, 2015

being weak

     I sit in my family doc's exam room. Well, sort of sit. I'm avoiding my left side altogether. It's less than 36 hours after my I&D and I'm feeling weak, tired, ineffectual. In retrospect, I had no idea HOW poorly. My doc enters into the room and the smile fades from his face. His change in demeanor should have clued me in. He exams me and I know what needs to happen. I just need to hear him confirm it. I need some reassurance that I'm not just being a wimp. Throughout everything with my brother, my dad, my son....I could always remain objective. I could split my psyche and remain clinically cold and objective. I was Atlas. But not with myself. I am afraid of being weak. Of being a failure. Of not being strong enough to get to work. I lose all objectivity. It's one thing to need time off for a dying relative. But it's a failure of self to need it for one's own self. I emotionally need him to validate what in my head I already know.
     "I need vanc, cefepime and flagyl, don't I?"
     "Yeah. Yeah, you do. You need to go to the ER."
     "I was just there. Can't I sleep in my own bed and go in the morning."
     His look says it all. "No. Now."

November 30, 2015

getting worse yet

....I crawled into a wheelchair writhing in pain, able to sit only on the right side as my left burned with flames.  Being in scrubs and a Smith Hospital coat got me admittance into their ER pretty quickly.  Doctors take care of their own just like any other profession.  The senior resident came in, examined it thoroughly throughout my screams and asked me what I wanted to do.  I could have it drained by the surgery team in the OR, or they could drain it at bedside.  Stupidly, I said, "I don't want a full work up.  Just lance the thing and get me back on my feet."  After all, I&D (incision and drainage) was the curative and definitive treatment for abscesses.  Besides, I had to get back to work the next day.  Well, the same day since it was already 1 am.
     The attending strolled in a bit later, took a very brief look, saw me jump off the bed and said, "I'll take the resident's and your word at it.  We'll get you set up here briefly."
     I desperately needed something for pain.  The doc again asked, "what do you want?"  The nurse quickly gave it to me and it barely took the edge off.  I asked for another dose when it came time to start sticking the lidocaine in my ass.  I knew the lidocaine was going to hurt.  I asked the doc if it was ok if I cussed a blue streak.  He replied, "of course, it's the ER."  What I did NOT expect was the incision of the scalpel to hurt so I let the expletives fly freely from my mouth...

IMAGINE NASTY, DISGUSTING PICTURES HERE (because I do have them but I won't post them for y'all's sake)

...as the pus and blood gushed out in substantial amounts.  I'm screaming and trying to breathe through the pain while the ER doc apologizes.  I think I may have yelled back at this point, "don't apologize, just open the damned thing up!"  So he does.  He appropriately warns me first and in go the hemostats to start blunt dissecting open any remaining deep pockets of pus.  Imagine sticking closed blunt scissors into an already gaping wound and then jabbing them around while opening and closing them.  The opening action bluntly dissects open any walled off areas.  It's necessary to open everything or the I&D won't work.  And he opens everything.  By this time I'm hoping to just pass out from the pain.  No such luck.  And I thought the scalpel pain was bad.  It feels like there are several poison tipped knives sticking out of my butt.  He finally finishes and I weakly ask for some more pain medication as well as an anti-nausea med.  Now I remember why surgery always did these in the OR under general anesthesia.  They let it passively drain for a bit and make sure I'm ok before cleaning me up and sending me on my way.  I foolishly forget to ask for more anti-nausea med when I get yet another dose of pain med for when the lidocaine wears off.  My wife drives me home and I remember little, being in a stupor by this point.  The next thing I know, I'm stumbling out of the car and bent over in my yard at 3 or 4 in the morning throwing up a lung.

November 29, 2015

hard time of the year

“I felt like crying but nothing came out. it was just a sort of sad sickness, sick sad, when you can't feel any worse. I think you know it. I think everybody knows it now and then. but I think I have known it pretty often, too often.” - Charles Bukowski

     Holidays.  Holy Days.  Days that are sacred.  Thanksgiving.  Giving of thanks.  Gratitude.  But what happens when there is no gratitude, where there is nothing sacred, nothing holy; there is only that sad sickness?  Wherein there lies a physically insurmountable obstacle to those you love, why bother?  Or, as Job bluntly put it, "Since I am already found guilty, why should I struggle in vain?"

it gets worse

     My wife and I are driving home from a quick whirlwind trip on my day off.  At the beginning of the day, I knew something was off and I was starting to sit funny.  I thought that if I could get home and get on some antibiotics, I'd be good.  Oh, how naïve that thought would be in retrospect.  I had started to develop a furuncle in, shall we say a rather delicate area as a result of the gastroenteritis.  By the evening on the way home, I was writhing in pain.  My wife suggested, "maybe we just keep driving right down to the med center."
     Being the idiot that I am, I wanted to know what I was dealing with.  But I couldn't exactly see it so I asked her to pull over at a McDonald's.  Like a cowboy who has been on the trail for 6 months, I limp bowlegged to the bathroom, lock the door, and with the help of modern technology, took a selfie that I will not post out of decorum.  Holy shit.  This was no furuncle.  This was an abscess.  And a significantly large and angry one at that.  Calm down.  Deep breath.  I need to examine it to see how bad it is.  So again with the help of my iPhone high definition live camera feed, I used it as a mirror to guide my exam.  I began to palpate to see how much fluid was in there and how indurated it was.  I didn't even have time to let loose a string of expletives because I about passed out from the pain the instant my fingers put pressure on the abscess.  That would've made for an interesting viral video and a very confused McDonald's employee who found me.  I stood back up to catch my breath, try to avoid passing out, and got dressed after about 5 minutes.  I hobbled slowly back outside and told my wife, "Yeah, you're right. Just go straight down to the ER."

November 20, 2015

wheel within wheels

http://xkcd.com/1605/

This is what I think of when I see companies like 23andme and others claiming they've figured out how to predict your health. My not so insignificant time spent in pharmaceutical research and development also bears out this comic. It's amazining we can treat anything given how complex the human body is. 

November 18, 2015

just the beginning

    Nearing the end of the day, I was checking my lidoderm patches to see how well they were sticking and assessing whether they'd survive the drive home or whether they should just be removed. I then noticed a streak down the middle of my scrubs. The back of my scrubs. I was struggling with the beginning of a bout of gastroenteritis and lets just say things were starting to get raw down there. So I had the brilliant idea to use vaseline to help protect the skin. But it had soaked through to my scrubs. And I wasn't wearing my long white coat either. Great, I had been walking around all day with this streak on my ass and no one bothered to tell me that it looked like I shit my pants. If only that had been the worst of it....

November 10, 2015

design flaw


Other than being funny, this cartoon will make more sense in days to come. 

http://abstrusegoose.com/571

October 30, 2015

vanity

This may sound vain, but everytime I physically sign a prescription, a birth certificate, a form, etc and put the requisite MD after my name, I feel a twinge of giddiness. It'll probably take a bit longer for the novelty to wear off as so many of the prescriptions are electronically signed now.

October 22, 2015

my life

     It's a slow night and I can't be more relieved. There is only one lady in labor and delivery; triage is completely empty. The woman was barely contracting a couple of hours ago so I figure it won't be until 2 or 3 in the morning until she delivers. My oncologist calls me to follow up about getting in to see an endocrinologist. During that phone call, the delivery page goes off overhead. I start running down the hall while still talking about my own unknown health. I tell the doc I have to go. Emergency. I run in and the baby just came out. Fortunately, another doctor happened to be in the room while the woman started pushing. I massage her uterus and then start delivering the placenta, collecting cord blood, making sure she isn't bleeding, etc. We count up the sponges and we're one short. Shit. We can't find it. The only remaining place is the biohazardous trash. So while still fully gowned up I'm digging through the trash looking for a bloody sponge while my phone keeps going off as my oncologist is trying to call me back. Did I mention that the trash consisted mostly of feces laden pads as the lady began pushing too early? This is my life. I'm digging through a biohazard trash bin filled with shit while my oncologist is calling me about seeing an endocrinologist. I can't make these metaphors up.

October 17, 2015

pain continued

     It's 4:33 am. The constant barrage of patients streaming into triage all night has abated. My back is fried and I know I will pay for it. But underneath lies a sense of pride in doing a job well done. With every shift I gain in knowledge and experience. The patients are well cared for and I continue to grow. It seems worth the sacrifice. I lie down on one of the triage beds in a room hardly ever used. I intend to go to sleep for an hour or two. But the adrenaline that carried me for 11 straight hours is now depleted and the pain starts to resurface. I lie in the bed on my left side. My lower left lumbar cries out after just a few minutes. I flip over to my right side as lying on my back is a nonstarter. The right shoulder complains just as loudly, the result of a spinal defect combined combined with a football injury decades ago which has left me with a built in barometer. Sleep is not going to happen. I pull out my iPad and bring up Netflix intending on using that age old tested method for treating pain called Diversion. Ten minutes into it, I'm restless and cannot get comfortable. I try getting back up to walk it off. It works for about 60 seconds before the fatigue that caused the pain returns. I lie back down and try meditating. I struggle to control my breath and focus on it instead of the physical pain. I lie there in the dark and the thought arises in my head, "This is what hell must be like. Or, at least some version of hell. To be trapped in one's own body and unable to escape the pain signals it is creating. The pride is long gone and all that is left is physical pain."

October 14, 2015

cost

     The first time I saw the patient, it was for a wellness exam but I sensed an angst that lie below the surface. But it's best to let these things evolve and focus on creating trust with the patient. The second time the patient came back in, the nurse came and whispered to me, "their pulse is in the 110s. I think they're really anxious about something."
     I walked in and asked, "how are you doing?", to which their reply was noncommittal. I set the chart, the pen and my stethoscope down and asked if everything was ok as I sat down. The breaths started coming deeply and tears started flowing. I reached out and offered my hand. They grabbed it and started to try to talk. To give words to the anxiety, to the trauma that created the anxiety. But the words were impotent. So I told them to close their eyes, focus on my voice, take deep breaths in and let them out completely. I instructed them to squeeze my hand as hard as they could with each breath in and relax on the exhale and just keep focusing on my voice. It must've lasted quite some time because the nurse peeked her head to see what was taking so long. One quick look appraised her of the situation and she quickly closed the door. 
     I could begin to tell the patient was starting to turn a corner and the adrenaline coursing through their veins was starting to ebb. I ever so gently slid my hand to feel their pulse as they continued to squeeze. What was that. That was a skipped beat. That happens. Maybe it's nothing. But I continue to feel. Shit. Another skipped beat. And this is not afib. I now have to tell this patient that they likely have an arrhythmia. And now I have to get an ekg. I have to let go of the patient's hand before they are ready. It is incredibly painful for me to do so but it's a necessity. Somehow, I manage to coax the patient to break that healing physical connection and let cold reason dictate my next steps. There is a cost to be bourn by both the patient and myself for this schism. 

October 9, 2015

pain

Quote Originally Posted by vanslix View Post
And do yoga. For that omission, I have no reason, no excuse, not even a made up reason. If I'm honest, when I truly quiet my mind, I don't like what resides there. I've stopped meditating, too. Too many demons. It's easier to press a bar and exorcise them that way. But I'm realizing that's a temporary solution, albeit a damned effective one. Surely, there can be balance...
I woke up this morning feeling like the Tin Man. Reason is I actually got some decent sleep (had last night off which was bliss) which means everything sits in one place. So I wake up in some serious pain. Guess I called the end to that pain flare a bit prematurely. Was going to go do deadlift to burn off some anger. And then I remembered the post above in response from Chris advocating yoga. While iron has been a tremendous coping mechanism, I think it might be time to start to dig deeper for some internal healing. Plus, I have to work tonight. With that in mind...
Cycle 2 Week 1
Waist - 43 3/4". Not as rapid as I wanted but so be it. It's going down.
Zen Day
-Meditate for 15 minutes with heating pad on my back.
-yoga for 20 minutes.


Yoga definitely helped, at least short term both physically AND mentally. Thanks, Chris. I'm starting to wonder medically about my pain which extends beyond just my back. I played football for 3rd grade up through college so I know what aches and pains are. These go beyond that. My family doc thinks it's just the wear and tear from football and hiking. But he recommended seeing a pain specialist which kind of pissed me off at first being a family doc myself. But I think another pair of eyes is warranted. So I'm going back to my interventional pain specialist for a more thorough exam. I'm also seeing a medical pain specialist in November which also focuses on mind-body connections. No insurance but I'm at the point where paying out of pocket is worth it.

And thanks for everyone's input. It's absolutely helping me to sort this out in my head. Talking to my colleagues doesn't help. They're all a bunch of young pups, super over achievers who've never entered into Dante's Inferno before. I think every resident should have an electrical cattle prod strapped to them for one week where it gives them low level but painful continuous shocks for just 1 week so they get just a taste of what chronic pain truly is. WHILE THEY CONTINUE TO WORK.


I wrote the above at a forum about lifting heavy things and then setting them down.  Weight lifting has been a lifesaver these past 5 years for me.  But I'm reaching a point where something internally is beginning to churn.

October 4, 2015

i've been everywhere, man

I've been everywhere, man
I've been everywhere, man
Crossed the desert's bare, man
I've breathed the mountain air, man
Of travel I've had my share, man
I've been everywhere
- Johnny Cash, among others

     A new month means a new job.  I go to a new place whether it be a different hospital or a different clinic.  I have a new boss.  In fact, I often have different bosses on different days.  I have different colleagues on different days, too.  The hours?  Those change, too.  Last month was working in a surgery outpatient clinic.  October is working nights delivering babies and triaging pregnant women coming into the hospital.  Except for one day where I work days in my own clinic seeing my own patients.  Sleep hygiene?  What's that?
     I've had to learn to adapt in order to survive.  After having been in the working world for so long, I'm not used to this constant change.  I'm the type of guy who goes to the same restaurant for ten years and orders the same thing.  I walk in, and they say, "the usual?" 
     Plus, I'm not young like my other colleagues.  And frankly, I don't have a spine like anyone of any age according to my neurosurgeon.  I can't pull a 14-16 hour shift night after night sitting at the triage desk.  Pain simply won't allow it.  So I make an arrangement with the nurses this month.  When no baby is close to dropping and no one is in triage, I'm lying down in one of the triage beds curled up in the fetal position.  It's not to sleep.  It's to take the strain off my back.  And I'm not really asking.  I'm just being polite.  In return, I change the sheets and leave the bed as I found it.  It's either that or I regress to a cane.  Or, according to my son and my dad, a wheelchair is not too far off in my distant future.

September 25, 2015

you never know where you'll learn

     Every night I deliberately choose her line to pay for my dinner, even if the wait is longer. Initially. it is because she always makes sure I get my full $10 worth of my meal ticket (we don't get change back). And if I go over a quarter or two over, she doesn't care and lets the 50 cents slide. But as the nights add up, I choose her line just to talk to her. She has this effusive, contagious personality and it brings a light into my nights while I'm on at the hospital. In some way, I am learning to become the doctor I want to be as much from her as I am from the medical staff. I'm not effusive and outrageous like her so I choose my own strengths. I'm strong, a rock, something to hold fast to during the storm. I constantly aim to bring that calm, confident mood to the patient's room just like she brings it to her cafeteria line.

September 22, 2015

the companionship of the dead

As we grow older we have more and more people to remember, people who have died before us. It is very important to remember those who have loved us and those we have loved. Remembering them means letting their spirits inspire us in our daily lives. They can become part of our spiritual communities and gently help us as we make decisions on our journeys. Parents, spouses, children, and friends can become true spiritual companions after they have died. Sometimes they can become even more intimate to us after death than when they were with us in life. Remembering the dead is choosing their ongoing companionship.
- Henri Nouwain, author of "The Wounded Healer"

September 21, 2015

well, do I have cancer? no

"At this time we cannot find any detectable presence of cancer," were the words spoken through the phone. Not that I wasn't relieved, but the qualifier 'at this time' sticks with me. The doc knew my family history and seemed to give voice to that thought, "when will it be my turn?"
     But for now I need not worry about cancer. The oncologist is still concerned about what happened, though. He intends to send me to a top endocrinologist for yet another work up. I'm beginning to get sick of doctors. 

September 18, 2015

black badge of courage

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.

     I'm striding down the maze of hallways at midnight to the ER to do yet another admission. I'm tired and my back is feeling it from the constant sense of urgency that comes from an already busy night. I'm bent over ever so slightly as a consequence so my gaze is directed downward. I guess that's why our eyes met. He was in a wheelchair and the hospital gown gave his status as a patient away. He was lost and asking me for directions to the cafeteria. As I have trouble navigating out of a wet paper sack due to my lack of sense of direction, I told him to follow me as it was on my way to the ER.
     All I ask him is how is he doing this evening. That is it. Nothing more. Just being polite really. And slowly but steadily he begins to tell me troubles. Mid twenties. Made a living by the sweat of his brow and working with his hands. And now he is suddenly paralyzed because of multiple lesions in his brain. The neurologists think maybe infection, maybe cancer, maybe who knows. And he's telling me this without much detectable emotion but he's telling it in a way that is highly detailed. And it strikes me that he hasn't had the time nor the opportunity to talk about this, much less digest it. He's using me to help sort out all the thoughts and emotions whirling in his mind and heart. I do all that I know how to do which is to be fully present and just listen.
     After he found the cafeteria, he thanked me, shook my hand and abely rolled himself to get something to eat. In my mind, I'm wondering, "what the hell just happened?" Later, I ask my wife if I have something tattooed on me visible only to those in severe existential pain that says, "bear unto me the troubles of thine soul." She only half jokingly calls me an Angel of Death, but a merciful one. And, yes, she says that people can indeed feel something about me that invites them to open up. They can sense my pain like a dog can smell fear. I'm at a loss how they know but she's the intuitive one. And after knowing each other for over two decades, I've learned to trust that intuition of hers.

September 15, 2015

September 11, 2015

well. do I have cancer?

     There is a common axiom of prioritizing what matters most during your training. It is infinitely wise its brevity. Eat, sleep, shower. In that order, depending on the person. Me? I eat on the way home in the car so that gives me one less thing to prioritize. So where does one's health fall into this scheme? Traditionally, residents take horrible care of their health during training. For me, I have multiple health issues so those get triaged as to what is the most important at the time. Pain.
     So I went to a pain management specialist to receive spinal injections in an attempt to reduce pain. I did actually go and get the bone marrow biopsy done so why no results? It undid some of the pain relief I received from the spinal injections which then impacts sleep. Eventually, I just ran out of sleep. I could tell from my blood counts at the time of the bone marrow that cancer was becoming less and less likely.
     Plus, I figure if I had something ominous, my oncology doc would've called me. I bumped into them getting out of an elevator while they were getting in. Not enough time to discuss all the subtleties and nuances of a diagnosis and their face did not show any sign of concern. Plus, we need to discuss that if it wasn't cancer that altered my blood so that it leaked from my skin with simple pressure, what in the world was it? And to be honest, I don't have the physical or emotional energy to start another workup with yet another specialist. So I will wait for my appointment at the end of September with the oncologist fairly confident I don't have cancer. So, next month I'll get the ball rolling on the next specialist work up. So do I habe cancer? I hope not, but the final answer will be a couple of weeks waiting and I'm fine with that.

September 7, 2015

labor day

No other country, I am told, makes a like observance. But in America this high tribute is paid in recognition of the worth and dignity of the men and women who toil.
You come here as representative Americans. You are true representatives. I cannot think of anything characteristically American that was not produced by toil. I cannot think of any American man or woman preeminent in the history of our Nation who did not reach their place through toil. I cannot think of anything that represents the American people as a whole so adequately as honest work. We perform different tasks, but the spirit is the same. We are proud of work and ashamed of idleness. With us there is no task which is menial, no service which is degrading. All work is ennobling and all workers are ennobled.
—Calvin Coolidge on Labor Day in 1924.


I'm still glad I had it off. 

September 3, 2015

payment

When I tell people I'm a doctor, they think of one of two things. A) they want me to diagnose some ailment they have or B) think how rich I must be. Let me correct the latter presumption. I just got my first paycheck. I make just over $11 per hour. The drive through at the Taco Cabana I just passed through to pick up dinner(?) at 10:30 am was hiring at $9 per hour. But to be fair, that $11 is after taxes, liability insurance, disability insurance, and most importantly, health insurance. So am I mad to be making so little per hour for such highly skilled labor? Absolutely not. I'm thrilled to get it. I've been too long living off of student loans and the graciousness of family members. That doesn't feel good to me deep down. So while I'm not exactly rolling in the cash, it's nice to know I don't have to worry about my house note anymore. Well, I don't have to worry about it as much.

August 31, 2015

good part III

After being transfered to the ICU, the patient never regained consciousness and he passed away. Others on the team were surprised by his passing. They thought he'd regain consciousness. I knew better from the moment I admitted him. You just don't recover from that. And I'm not sure my silent prayer for peace and a good death came to fruition. It's not my first death. Most docs don't forget their first death. But you NEVER forget it when it's your brother as the patient. But I still feel the loss of this patient, nonetheless.

August 29, 2015

loss of an titan

So often with titans in the medical field, there are egos bigger than buildings named after them. Not so with Dr Red Duke. The man was a legend, is a legend. One in a million. All those cliches, except in case they ar a absolutely true. He was larger than life and a model physician for everyone he touched. The patient ALWAYS came first and there was not even the slightest hint of pretentiousness.  He didn't care if it was a CEO, a president of the United States, a med student, or the cafeteria worker or the janitor. He treated everyone the same, and that was with dignity and respect.  He will be sorely missed. The story with videos at the link below are absolutely worth watching. And they are not embellishment. This cowboy, this giant among men was the real deal.

https://www.uth.edu/drredduke/

good, part II

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.

Staring at me is a text message from my upper level resident saying, "GOOD call on the CT. It's likely cancer."

     Implied is that I did good by correctly assessing the patient and ordering the best test to cut to the chase. But, good? I was off the next night so I did not have the opportunity to speak with patient. And the following shift I was off to take care off my own health problems by getting my bone marrow biopsy. Insert a two day training course on advanced life support for obstetrics and I've missed the patient for days now. I finally come back on only to find out the patient went downhill rapidly and ended up in the ICU.

     A sense of regret washes over me. I only performed HALF of my job. I was there to diagnose the ailment. But I was not there to console the patient. The rule of thumb is that is the job of the day team, not the night team. But not one of them knows pain like I do. And I hope they never do. But I still feel as if I let the patient down. So before it gets too late into the evening, I stroll into the ICU where it is no longer my domain. I stand and watch the patient breathing with a ventilator and say a silent prayer asking for a good death and peace for the patient and the family. The nurse looks at me a bit strangely and asks who I am. So I answer honestly. I admitted the patient and just wanted to do right by the patient by following up, no matter how too late it is.

So, did I do good? I honestly don't know. But I know how I will do it differently next time.

August 25, 2015

affordable care part II

     I lay face down as the tech prepped the area where they would be drilling a hole guided by a CT scanner into my bone to collect a bone marrow sample all in an effort to finally determine whether I have cancer or not.
     "Are you sure you don't want to be sedated?" the tech asks with a slight bit of concern. 
     "Trust me. Neither I nor you want me getting propofol or fentanyl. I'll start vomiting. And I'm talking projectile style. And y'all will have to clean up an awful mess. I'm fine with a small dose of dilaudid and versed."
     "You're the doctor."  Even as a patient, I'm addressed as doctor. I can't help it. It's not that I'm pretentious or want the prestige. It's just who I am. While waiting, a nurse began asking about diabetes drug options so I gave a list of options to bring up the next time they saw their doctor. The patient, sorry I was the patient and they the healthcare worker, walked away armed with far more information than they had before. And it just feels so natural to me. 
     The IV meds are pushed and the metal rod about the size of a good sized Phillips screwdriver is bored into my bone. The interventional radiologist scans me with the CT and then readjusts it. Repeat several times. And I'm not thinking about the physical pain. Acute pain I can handle just fine. It's the chronic one that wears me down. No, I'm wondering why did this take so long? Why did I wait with the potential diagnosis of cancer looming over me? In a word, Money. I had it scheduled before I was to start residency. After all, it was a lot easier to do then with respect to scheduling. But with my "affordable" care act insurance, this procedure was going to cost me $4,000. To quote the infamous Inigo Montoya from The Princess Bride to the government, "I do not think that word means what you think it means." So I had to wait until I started residency and got on a good insurance plan. So here I lay with a rod being shoved back and forth now able to get the necessary test run because I'm fortunate enough to be in the right labor pool. I am grateful for being able to finally get the test but I'm also not naive enough to think that our healthcare problem and it's looming insolvency is moving in the right direction. 

August 23, 2015

good part I

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.

     It took less than two weeks. I pull a stool up to the bedside in the ER to get the patient's story. I cinch the curtains shut to try to get as much privacy as possible but they remain impotent against the constant noise of controlled chaos that is a tertiary level ER. It becomes readily apparent after listening for five minutes that this story will not have a happy ending. I explain to the patient what general tests I am going to order, how the process of being admitted to the hospital works, and always end by telling the patient that I am here all night so if they need anything, just have the nurse give me a call. And I genuinely mean that last part. No matter how tired or what time of the night it is, I always answer the phone with a pleasant voice saying, "family medicine, this is Dr Isaac."
     I quickly enter in the admission orders along with a battery of tests to rule out some common things. But I know the most important one - a CT scan - and order it without hesitation. By this point, I have earned the trust of the third year resident so that he had deemed me competent enough to plan my own orders. He will review them to make sure I didn't forget anything but the point of being a doctor is learning to think on your own.
     A couple of hours later, I go home and hurry up and sleep. I only have a limited number of hours to eat and sleep before turning around and coming right back to the hospital. When I wake up, I check my phone for any texts or calls that I missed while sleeping. Staring at me is a text message from my upper level resident saying, "GOOD call on the CT. It's likely cancer."

August 17, 2015

the physical form

Working long and odd hours, I often get the gym to myself. I looked in the mirror and thought, though this physique is no Adonis, I wondered, does this body yet have cancer? I still do not know. Another consequence of working long and odd hours is that it's difficult to take care of yourself. I'd rather be asleep than waiting in a doctor's office. But the bone marrow biopsy is a day away and that shall reveal all.



August 15, 2015

Every morning I come home from work strung out on adrenaline and caffeine thinking to myself, it's astounding how much I can learn in just one night. And every evening I drag myself back to the hospital and a different patient comes along that makes me think to myself, I don't know jack shit.

August 7, 2015

vampire test

     I have been accused, justly I might add, of having a bit of an Eeyore personality.  My wife is my opposite and so at times will needle me initially to try to get me to smile, but failing that, then just to get any reaction out of me.  So it was the other day when I was stressed about not knowing whether I had cancer or not, my back pain was flaring up, and I had some work issues causing some stress.  So she poked, prodded and finally gave me a love bite, really more of a hickey than a bite, on my forearm which I admit did cause me to crack a smile at the absurdity of her action until I saw my forearm.  We both looked down.  On top of my skin resided a thin film of what medically would be called serosanginous fluid but in reality is blood with a bit of other fluid.
     Now, she didn't actually bite me.  She didn't bruise me.  But the capillaries in my skin are so congested with the excess red blood cells that they are easily ruptured.  Really easily, apparently.  I asked my wife if she tasted the salt of blood, to which she answered yes.  She then of course found it to be the funniest thing in the world at that moment that I'm oozing blood while I'm just thinking to myself, "This. Isn't. Normal."
     So the day before my next scheduled blood draw I'm curious what my red count is running so I just hand my forearm to my wife.  Yup, still elevated.  The results the next day confirm it.  Time to lower the dose of my medication again.

Disclaimer: The vampire test should only be performed under the supervision of a trained physician.

August 4, 2015

affordable care part I

Out-of-Pocket Costs More Stressful Than Cancer in Texas

Nick Mulcahy
July 31, 2015
In a finding that points to the overwhelming impact of out-of-pocket expenses in American cancer care, more than 30% of patients with advanced cancer rated their financial distress to be more severe than their physical, family, and emotional distress, according to a new study from Texas.
Of the 149 study participants, 72 received treatment for advanced cancer at a general public hospital in Houston and 77 received treatment at a private comprehensive cancer center.
Not surprisingly, the poor folks at the public hospital were a lot worse off.
In fact, a novel self-reported survey revealed that the average "intensity" of financial distress in the public hospital patients, measured in a 10-point scale, was more than twice that of private center patients (8 vs 4; P = .0003).
But some degree of financial distress was present in just about all public and private patients (90% vs 86%).
Financial distress was calculated as the percentage of a patient's total family income spent on out-of-pocket cancer costs in the previous month and the related subjective stress.
Median monthly income of the public patients was lower than that of the private patients ($940 vs $3000).
The overall findings are "concerning" because physicians lack the tools to uncover financial distress, according to the study authors, led by Marvin Delgado-Guay, MD, from the University of Texas M.D. Anderson Cancer Center in Houston.
"The vast majority of the instruments aimed at determining symptom distress and quality of life do not include a financial distress item," they write.
Their study was published online July 23 in the Oncologist.
Financial distress was also associated with anxiety, depression, and poor quality of life.
"I am not surprised that such a large proportion of patients consider financial distress to be more unbearable than other forms of distress," said Yousuf Zafar, MD, from the Duke Cancer Institute in Durham, North Carolina, who, along with his colleague Amy Abernethy, MD, coined the phrase "financial toxicity," as reported by Medscape Medical News.
Patients are at risk of suffering in silence.
Dr Zafar said that patients are ill-prepared for the treatment-related financial burden and do not know where to go for help. "As a result, patients are at risk of suffering in silence," he said.
Dr Delgado-Guay's team and Dr Zafar agree that of all stressors a cancer patient faces, financial distress receives the least attention.
What can clinicians do? Perhaps use the Comprehensive Score for Financial Toxicity (COST) — a questionnaire developed at the University of Chicago, as reported by Medscape Medical News — to help "identify possible interventions to ease patient suffering," the study authors say.
The 30% Explained
In their study, patients had breast, colon, lung, or prostate cancers that were recurrent/refractory (treated with more than two lines of chemo), locally advanced, or metastatic.
In addition to the COST questionnaire, which is not a validated tool, patients completed validated questionnaires to assess symptoms, psychosocial distress, and quality of life/functioning.
To assess the relation between money stress and other cancer-related stressors, the study participants responded to a series of statements made by the investigators, such as "I have more financial distress than physical distress."
Financial distress was reported to be more severe/stressful than physical symptom distress by 45 patients (30%), than distress about physical functioning by 46 patients (31%), than social/family distress by 64 patients (43%), and than emotional distress by 55 patients (37%).
All responses were significantly worse for patients treated at a public hospital than at a private center (P < .05).
When patients consistently report a high level of physical, spiritual, and emotional distress, clinicians should explore the possible presence of financial woes. In other words, when ongoing high levels of distress of any kind are present, expect that financial distress is also present, say the authors.
However, they caution against generalizing their findings because only two institutions were involved.
The authors and Dr have disclosed no relevant financial relationships.
Oncologist. Published online July 23, 2015. Abstract

August 1, 2015

it's official

     While I have filled the shoes of a doctor multiple times over with my family, I have now officially performed my first formal act as a doctor while working nights this month. Prescribing tylenol. Nice way to ease back into things. Real slowly. Fortunately, I'm not as dumb as the intern on Scrubs and had no need to page anyone on the dose.


membership has its privileges

     I am down in the medical center to sign some more forms for work.  But I figure why not kill a couple of more birds with one stone.  Or, a coat in this case.  I'm supposed to come back down the next day for another blood draw.  But I really do not want to drive 60 miles round trip just for a blood draw when I could do it today.  I also need to get in to see a pain management specialist to see about doing something different for my back.  So when I get out of my car, I throw on my white coat that, contrary to my wife's opinion that the md should be lowercase until I complete residency, has the capitalized MD after my name.
     I sign my forms and head over to my oncologist's office.  It's quicker to walk outside but it's flirting with triple digits which is why I hate wearing the white coat in the first place.  Who would want to put on an extra layer of clothing in this climate?  But I'm realizing how much of a status symbol it really is.  So I stay inside and take the longer but air conditioned cross walk over to the office.  Instead of going through the 10 layers of bureaucracy to sign in, I simply casually walk back to the phlebotomists.  They like me because I can tell funny stories about their favorite doctors from when I was in med school.  I ask, and I must add nicely not just because I treat nurses special but because I treat all (or try to) human beings as I'd want to be treated, if they could at all possible squeeze me in.  One look at my coat's insignia and she puts her arm on me and warmly says, "we got you" with a smile.
     Five minutes after the blood collection, I'm walking from the oncology office to the neuroscience center (I'm a walking disaster).  I find out that they finally got an in house pain management specialist.  So I walk to her office suite.  It's near the end of the day so no patients are left in the waiting room.  I briefly introduce myself to the person at the desk and less than five minutes later the doc's medical assistant walks out.  I briefly explain what's wrong with me, what their spinal neurosurgeon colleague upstairs said about me (for free), and that she'd like me to try spinal injections to get some sort of relief from the chronic pain.  And I will never forget her answer because it was so kind and couldn't have been more appreciated.  "Well, we don't want to waste your time so do you want to come in for the visit and get the injection the same day?  We can make you the last case of the day since you're working nights and you can get some sleep.  We can squeeze you in next week.  Will that work?"
     I wanted to hug her.  The previous pain doc's office I tried to call first didn't answer, second time put me on hold and third time told me they were booked until September because the doctor has been on vacation and is going again.  So getting this royal treatment felt wonderful.  I'd like to think they treat all their patients this way and maybe they do.  But I also know it's because I'm a doctor for the same institution, albeit a resident.  But I figure I more than paid my dues with earning that MD under the circumstances I did so I felt a little less guilty about getting special treatment.  I've lived enough catastrophes the last 5 years that I'll take a little grace and privilege whenever I can get it.
     By the time I'm walking back to my car, I'm checking my phone and some of my blood results are already back in.  It's looking less and less like cancer and much more like a bizarre reaction to a medication.  With that sigh of relief, any feelings of guilt for getting special privilege melt away.

July 30, 2015

impatience

     The hold music blandly seeps into my brain as the monotonous repetition makes me lose track of the time spent on hold.  It's been over 10 minutes by my phone's count.  And this is the second time I've called.  The first time I got tired of waiting at 15 minutes and hung up.  Wait a second.  What am I doing on hold?  I have a long white coat now.  I hang up, redial and listen to the automated now familiar menu electronically read through my phone into my car speakers.  "If you are a physician, please press 1."  I press 1.  In less than 5 seconds a courteous individual cheerfully answers the phone. "Hello, this is Dr. Isaac and I'd like to check if a patient's abdominal CT scan have been officially read by the radiologist yet?  Name and DOB are....Yes?  Thank you, sir. Have a good weekend."
     I fight rush hour traffic to make it to the imaging center to get a copy of the CT report.  MY CT report.  I've looked at the images myself and I can't see anything that jumps out at me.  No renal growths.  No GI growths.  On the bones I see my abnormal spine but no sign of metastases.  But I'm not as good at reading CTs as I am MRIs of the spine.  I especially am not good at picking up enlarged lymph nodes. There's a reason radiologists make the big bucks.  So I want to know the official read.  NOW.  It's Friday afternoon and I don't want to wait the weekend to know if there is some solid tumor I somehow missed.  I breathe a deep sigh of relief as I quickly scan the results.  IMPRESSION: benign abdominal CT.


Ruling out a renal adenocarcinoma is a big deal as it could present exactly like the way I am presenting.  And it's a nasty malignancy, not that there's really any good cancer.

July 12, 2015

what is it?

When you hear hoof beats, think horse, not zebra.
- common saying in medicine

     The logic behind this saying is that common things are common. So if you are in Texas and hear hoof beats, odds are very high that it is a horse and not something exotic. But what if what you hear does not resemble hoof beats? What if the results don't fit anything typical or common? That is the situation I find myself in now.
     On a routine blood test called a CBC (complete blood count), I had abnormal results. So my doc and I figured, let's wait three weeks and make sure it's not some fluke. It wasn't. The results repeated. Given that even the doctors involved are puzzled by this finding, you'll forgive me if his explanation is not entirely clear but I'll do my best.
1- I have a high number of red blood cells (RBC). These are the cells that carry oxygen throughout your body. Too many and your blood starts to get thick and viscous which makes the pump, aka your heart, work harder. So it's not something you want to blow off. There are multiple conditions that can cause this, including one of my medications.
2- Though I have more RBCs, the individual ones are significantly smaller and more pale. Why? It means they have less of the oxygen carrying molecule derived from iron called hemoglobin. The conditions I alluded to above that cause increased RBCs do NOT typically cause this type of response. It's starting to get weird now because the condition that typically causes this is called thalassemia. But that's a genetic condition that's present from birth. Mine just popped up now. There is a very rare acquired thalassemia and it is essentially a boe marrow disorder on par with cancer.
3- The amount of total hemoglobin is normal which implies that I'm NOT anemic. However, the individual amount of hemoglobin in each RBC is low. So mathematically, 10 RBCs with 10 hemoglobin molecules in each is a grand total of 100 hemoglobin molecules. But 100 RBCs with only 1 hemoglobin molecule in each one is still a total of 100 hemoglobin molecules. Confused yet? You should be.
4- even though my hemoglobin is "normal" my total iron stores are profoundly depleted. Now it's starting to get really confusing. Most doctors, even the smart ones are scratching their heads by this point. What depleted my iron stores? Do I have a GI bleed? Is there a tumor using it up? Is the out of control growth of the RBCs using it up faster than I can replace it?
5- I have an elevated white count. Now it really starts to get confusing. An elevated white count is usually a sign of something like a serious infection or trauma going on - pneumonia, sepsis, appendicitis, severe trauma like a car wreck. Or, cancer. But I'm walking around doing normal day to day stuff. I'm not laid up in a hospital bed. It's most certainly NOT associated with an elevated red count due to a medication.

So there is no horse in these hoof beats. It is a zebra no matter what. It might even be an eland. The top two diagnoses that are being ruled out are both statistical anomalies. Both options are being pursued concurrently and this is a GROSS oversimplification.
1- stop the potentially offending medication.  This will not be fun or easy. I am against doing this but the oncologist and my family insist. I'd prefer a much lower dose but I'm not supposed to self treat. By stopping the medication, though, it is the quickest way through the mud. So the doc has a point. Stop it and see if the abnormal CBC resolves. If it does, ipso facto, it's the drug. And if it is, it's potentially worth publishing as a case report as it's unheard of. This is the more desirable of the two outcomes, obviously. But we don't get to pick.
2- start the cancer work up. Test my blood for some common mutations that could cause some blood cancers that may be presenting atypically. Get a CT scan of my abdomen to ensure there are no gastric or renal tumors that could also present like this. And finally, a bone marrow biopsy to make sure there are no physical, genetic, or chromosomal abnormalities present. If these are all clean, then it'd take cancer off the table. If not.....well, I'll jump off that bridge if and when that's where my road takes me.

So I get picked, poked, and prodded, not to mention a high tech image of my innards and some high tech analysis of my genes and chromosomes. And though I am exceedingly grateful that I am at the world's largest medical center and have the connections to move through it like water, I still wait nervously like any other human being.

July 10, 2015

resolve

"Nay, I will not walk backward in life," said Turin.
- Children of Hurin by JRR Tolkien.

     We step out of the elevator on the 29th floor looking for the correct office suite.  But it is not hard to find as it takes up the entire 29th floor.  On the wall is an unmistakable sign but I only see one word.  Oncology.  A lump in my throat takes hold, I take a deep breath and then walk in followed by my wife and parents.  We are at an oncologist's office.  A cancer doctor. Again.  Is it cancer?  Is it something less ominous?  We don't know yet.  But it is beyond the realm of a family doctor.
     This role is foreign to me.  Fate has placed me squarely time and time again in the role of doctor/caregiver of family members.  But what do I do when I am now the patient?  It was the doctor side of me that got me quickly in to see an oncologist.  It was the doctor side of me that reached out to colleagues and had three separate opinions before I even met the oncologist.  In the room, I can't help but ask about certain tests.  But the patient finally had his say.  I tell the doctor my family history and can see the grimace on his face when with my eyes turning red but my voice firm, I then say, "so when I had an abnormal and bizarre result.........it scared the shit out of me."

July 8, 2015

the past

     Waiting with the Sword of Damocles potentially hanging over you generates a lot of fears, especially when one has endured what I have experienced.  So I went back to the past me, to see if he might have anything to say.  He did, indeed.  I wrote this of my brother four years ago in the summer of 2011, almost to the day, shortly after he had passed away.  What will I do, indeed?

pain
     My brother experienced severe pain.  A LOT of pain.  Pain was what sent him to the doctor where he received his death sentence.  So from his diagnosis until a few hours before he died, pain was ever present.  I can hear people's minds running, "if that was me, put me out of my misery.  I don't want to suffer."  Nobody wants to encounter that kind of pain.  Even our dad, in the midst of fighting his own grim battle told me that he will not suffer like that.  He will elect to die.  But my brother did suffer.  A large part of y'all may think that was due to a failure on the part of the medical establishment.  Maybe.  If so, then I would share some of that blame.  I accept that if it's true but I believe it to be more complicated.  I replayed the scenario over in my mind.  Over and over and over.  His grimaces, his walk hitched up short by the tumors present in hips, his limited range of motion of his shoulder, his grunts at the end when he could no longer talk.  I see these in my mind's eye like they were yesterday.  I'll carry those scars with me the rest of my life.  My own pain, though of a very different beast.
     At every doctor's visit, he had to rate his pain from a 0-10 scale.  0 is no pain.  10 is the worst pain of your life.  It's a standard way of assigning a quantification to a subjective quality like pain.  He NEVER rated his pain a 10.  I finally asked him, "what would it take to be a 10?  You look like a 12 from where I'm sitting."
     His reply?  "I think of some soldier who has his leg blown off and is bleeding out.  That's a 10 to me.  I don't have that so I'm not a 10."
    "Wow."  That's the only response I could muster.  Trying to explain how that soldier would be high on adrenaline and shock to blunt the response was useless.  He was clearly in severe pain.  But not a 10 to him.  It was that simple.  When a pain spike hit, he would reach for tylenol, freakin' over-the-counter tylenol at "extra strength".  He'd do that before reaching for morphine. 
    "That's like shooting a bb-gun at a tank," was my clinical advice.  "I take more when I get sore from backpacking."
    Not wanting to fail him, I strongly suggested that he try an antidepressant to assist in managing the pain.  There was data at the time that some of them could blunt musculoskeletal pain, similar to the type of pain that he had.  Cymbalta has subsequently been approved by the FDA for pain, regardless of depression status.  His response to me?  "I don't want to take a happy pill."
    So why was he in pain?  Did the doctor fail him?  Did I fail him?  I don't believe so.  The reason was two-fold.  First, he disliked medicine.  He took so many pills who could blame him for getting sick of all the side effects.  Pills, pills, and more pills.  But bigger than that, he never accepted his diagnosis.  He never reached that stage.  He refused to.  When someone close passes, there's a natural inclination to only remember the good things about the person and gloss over the difficulties.  There's a temptation to turn the memory into a myth.  The eulogy can become a mythology.
     But my brother was human.  He was a good man, but as human as the rest of us.  He had his own weaknesses and shortcomings.  Pain was a result.  Was it strength that kept him fighting and consequently in pain?  Or, was it weakness at an inability to come to terms with his impending death?  Harsh words, perhaps.  I feel I earned the right, though, to be able to ask them.  In all honesty, I don't think it's that black and white.  He was in pain because he fought.  He fought because he wanted to live.  He wanted to be with his family.  He also couldn't accept the inevitability of his diagnosis because he wanted to live.  Because of that, he was gone from his family a lot while he was receiving treatment.  Some of that treatment at the end would have been considered medically futile, in my estimation.  But he still did them.  Lots of shades of gray in there.  Strength.  Weakness.  Will to live.  Acceptance of death.  Do those terms even mean anything anymore?  Perhaps they are two sides to the same coin.
     So I ask those same questions of myself.  What would I do?  How much pain could I endure?  How much strength would I have?  What weaknesses of mine would be exposed?  What would any of us do?  And could anyone be faulted for making their choice?  After witnessing his struggle and suffering, I am not so quick to make a decision for myself, or for anyone else.  For him, it came down to this.  He chose pain in exchange for wanting to live. 

July 6, 2015

fear

“False hopes are more dangerous than fears.”  
- from Tolkien's Children of Hurin

     The phlebotomist struggled to find a vein willing to give up any blood.  Under normal conditions, they need not even use the tourniquet.  I just pump my fist and arm a few times, the vein pops right up, the needle quickly glides in, and that symbol of life pours out into the tube.  But now, it is different.  A tourniquet.  Both arms.  Multiple veins.  Bruises from all the repeated sticks. She queries, "are you dehydrated???"
     No.  I am not.  As soon as she hits a vein, I can tell that something is wrong with the life flowing through my veins.  It is thick and oozes into the tube as if it were molasses syrup.  And at that moment, I know the abnormal blood result seen three weeks earlier is a true result.  I do not need to see the lab report to know that both the red and white cells are elevated.  Again.  I tell my wife that the result repeated as we got into the car.  She refuses to go down that road.  Wait for the results.  Even then, you don't know what it IS, so don't start saying everything it COULD be.  But after so many battles, I am a weary, war torn soldier and I refuse to acknowledge hope.  Again.  Instead, fear remains.

July 3, 2015

deja vu

     The scene appeared all too familiar.  A sense of building rage, anger at the arbitrary nature of it all.  I flashback to the scene in my mind.  It is not hard to recall.  As sweat streamed from every pore, I stared in the mirror of the small gym gazing at my own eyes trying to see what, or if any, mettle lay behind them. Then, it was to judge if I was strong enough for my brother.  Today, the concern is drawn inward instead.  I am the object of uncertainty now.  I am the one who waits with dreaded anticipation.  For me.  Something is not right with my body.  And I do not know what it is.

June 11, 2015

he who wrestles with God

     Jacob was left alone, and a man wrestled with him there until daybreak.  When the man saw that He did not prevail against Jacob, He touched the socket of his thigh, so the socket of Jacob's thigh was dislocated, as we wrestled with him.  Then He said, "Let me go, for the day breaks."
     But Jacob said, "I will not let You go, unless you bless me."
- Genesis 32: 24-26

The clouds prepare for battle
In the dark and brooding silence
Bruised and sullen storm clouds
Have the light of day obscured
Looming low and ominous
In twilight premature
Thunder heads are rumbling
In a distant overture

All at once, the clouds are parted
Light streams down in bright unbroken beams
Follow men's eyes as they look to the skies
The shifting shafts of shining weave the fabric of their dream
- Jacob's Ladder by N. Peart

     Over the phone, my son wrestles verbally, emotionally, psychologically, spiritually with me time and time again.  In the day.  Late at night.  Countless hours.  A lifetime can occur during one conversation.  That understanding, that acceptance, that peace dances at the edges, forever eluding his (and my) grasp.  His illness, his Demon, his God, he will not let them go until he receives his blessing.



May 29, 2015

two little letters


 
     What a strange appearance after my name those two little letters make.  As if my name weren't long enough.  And oddly enough, separated by a comma.  A mere pause.  What stories there must be in the telling of the addition of those two little letters?  In this instance, a play with a professional actress, Megan Cole.  And what should this play be about?  An English professor dying of cancer.  What other role would I be "volunteered" for, of course, but an arrogant oncologist fellow trying to grasp his own humanity as life beats it either from him, or into him, depending on the point of view.  But it was a deep honor to be bear witness to Megan Cole's performance of death.  And life.  Just as I take the stories of all the patients who have helped me add those two little letters, hers is no less of potent tale.

May 22, 2015

remembrance

Through many countries and over many seas
I have come, Brother, to these melancholy rites,
To show this final honour to the dead,
And speak (to what purpose?) to your silent ashes,
Since now fate takes you, even you, from me.
Oh, Brother, ripped away from me so cruelly,
Now at least take these last offerings, blessed
By the tradition of our parents, gifts to the dead.
Accept, by custom, what a brother’s tears drown,
And, for eternity, Brother, ave atque vale
‘Hail and Farewell.’

May 16, 2015

the devil's hour

     For, he thought, it’s a special hour. Women never wake then, do they? They sleep the sleep of babes and children. But men in middle age? They know that hour well. Oh God, midnight’s not bad, you wake and go back to sleep, one or two’s not bad, you toss but sleep again. Five or six in the morning, there’s hope, for dawn’s just under the horizon. But three, now, Christ, three A.M.! Doctors say the body’s at low tide then. The soul is out. The blood moves slow. You’re the nearest to dead you’ll ever be save dying. Sleep is a patch of death, but three in the morn, full wide-eyed staring, is living death! You dream with your eyes open. God, if you had strength to rouse up, you’d slaughter your half-dreams with buckshot! But no, you lie pinned to a deep well-bottom that’s burned dry. The moon rolls by to look at you down there, with its idiot face. It’s a long way back to sunset, a far way on to dawn, so you summon all the fool things of your life, the stupid lovely things done with people known so very well who are now so very dead – And wasn’t it true, had he read somewhere, more people in hospitals die at 3 A.M. than at any other time . . . ?
      ......So what do we do? We men turn terribly mean, because we can’t hold to the world or ourselves or anything. We are blind to continuity, all breaks down, falls, melts, stops, rots, or runs away. So, since we cannot shape Time, where does that leave men? Sleepless. Staring.
Three A.M. That’s our reward. Three in the morn. The soul’s midnight. The tide goes out, the soul ebbs. And a train arrives at an hour of despair. . . . Why?
- Something Wicked This Way Comes by Rad Bradbury

     I know the passage well and I know I have used it before.  But as I sit here sleepless at 3 am, the passage becomes a talisman that protects me from myself.  I use the gifted writing as a defense to avoid relying on my own words as that would require rising up from the deadness within to draw breath, and give my pain its own language.  I naively assumed that graduating and starting residency would ease the transition of my own soul.  But here I am, still awake at 3 am.  Plus ça change, plus c'est la même chose.  The things change, the more they remain the same.

April 7, 2015

staying home


     I will be staying home at UT Houston for my residency training in Family Medicine.  Although my wife says it's lowercase md until I finish residency.  Then I can be a true uppercase MD.  She says she has to keep me humble.  Never have two letters meant so much.  No, it's not the letters.  It's what I underwent to earn them.  Those and the gray hairs.

March 27, 2015

dr death

     It seemed a befitting end to my medical school career.  The patient was dying.  Late 70s, history of Stage IV cancer, now with sepsis and respiratory failure.  All attempts at weaning the patient from the ventilator failed.  The patient's heart failure worsened the situation as fluid backed up into the already damaged lungs.  Then the kidneys began to fail which was the tipping point.  As I said, the patient was dying.  The family had been presented with end of life care on multiple occasions.  They refused.  They wished to keep going.  It was clear that the patient was in pain - groaning, writhing, restless, high heart rate.  But everytime we sedated them more, the respiratory condition got worse. 

     So on my last morning rounds of medical school, I stood tall, my voice loud so the entire group could hear and began, "just because the family wishes to keep fighting does not mean we lose sight of the obligation to the patient, who happens to be in pain from bone metastases.  It is clear that with multiple failures at weaning her from the ventilation, her respiratory failure is not improving.  In fact, it's getting worse judging by her compromised heart function, chest x-ray, the blood gasses, and her worsening acidosis compounded by renal failure.  What's the harm in keeping the patient comfortable?  She is dying either way.  She might as die without pain."  The attending nodded at me and told the nurse to bump up the fentanyl.

March 17, 2015

match explained

For those of you confused by The Match, join the club. I don't pretend to like it, understand it or defend it. Here's the official explanation, though. Wikipedia is pretty good, too. As the number of medical students has increased relative to residency positions, I'm not sure if the "logic" would still hold today. All I know, this is just one of MANY hoops to jump through. You stop questioning them pretty quickly to retain your sanity and to not lose sight of the real goal - to become a good doc. At least I did. But having come from the private sector first, I MUCH prefer the model of having job offers to consider and weigh against each other than this rolling of the bones.


March 12, 2015

writer's block


     I could say that my lack of writing was due to the Match process.  I did not wish to write anything that could drop me to the bottom of a program's list.  In part, this is true insomuch as it is a rationalization.  It is what I told myself when confronted with the fact that so much emotion has poured out through my fingers these past years and now my fingers desired a break.  In truth, I wished for nothing worth writing about.  Like an old photograph negative, my life has consisted of sharp contrasts in dark and light.  Though artistically interesting, it is a difficult environment in which to survive, much less thrive.  I am a doctor.  Though there were fewer people to watch me walk across the stage than were there to watch me start.  I have made great strides in being able to connect with patients at the deepest of levels and yet each step has cost me dearly.  Such is the nature of my life.  I am still attempting to search for a new life to build among the surreal rubble of boulders heaved down on me from upon high.  I've had enough of rolling boulders up hills to only watch them go down again.  I could stand some more moss.

March 1, 2015

if

    If you can make one heap of all your winnings 
    And risk it on one turn of pitch-and-toss, 
And lose, and start again at your beginnings 
    And never breathe a word about your loss; 
If you can force your heart and nerve and sinew 
    To serve your turn long after they are gone,   
And so hold on when there is nothing in you 
    Except the Will which says to them: ‘Hold on!’
- except for Rudyard Kipling's If

My ranking of the residency programs are in. Where am I going? I do not know. Things are out of my hands and now I wait. 

January 13, 2015

aging

The pictures alone make this article worth reading. I wish I could prescribe this to patients.