health insurance

     I got this from my health insurance company.  Not to worry, it says, my plan will become ACA compliant.  What worries me is they don't say what will happen to my premium.  Something tells me I won't be paying less.  I'll have to start writing my own prescriptions since I won't be able to afford seeing a doctor.

we have a pill for that

            “We’re still hurting a lot right now from when we failed a few days ago.  You’re not really going to do this, are you?” the three extra vertebrae in my back asked in disbelief.  They were clearly not happy with the notion of being jostled up and down repeatedly for two miles.

           

            “Yes.  I am going to go for a run,” as I started to slide my socks on.

           

            “Look at yourself, man.  You’re falling apart.  Have you noticed that your toenails on BOTH big toes are probably going to fall off?  Are we going to end up like that?  We can't grow back like toenails can.  Surely you haven't forgotten that much of the first two years of med school.”

           

             I wiggled the toenails and sure enough, both started to lift up like the pop top on a can of beer.  Both were the result of separate bike wrecks while riding at night.  On both evenings, I had already worked out for the day but by evening, the anger and stress had come back in full force.  So I went riding on the trails at night.  I had toe pain but the anger was less.

           

             “Oh, well.  Wouldn’t be the first time.  If it means anything, I'll jog slower.  I already quit running sprints for y'all.”

           

            “We do appreciate the no sprinting thing.  But today's run.....having us get all inflamed and pissed so you can’t walk wouldn’t be a first time, either.  Do you want us to go back to the way we felt two days ago?  Is that what you want?  You couldn't even stand up straight, for Pete's sake!”

            “Not really, but what are my options?  I can suffer more emotional pain or more physical pain.  It’s that simple.  It’s nothing personal against y’all, even though y'all are congenital defects.  You’re just going to have to hurt so that I can burn off some anger.  Deal with it.”

            “Good God, man, what are you going to do to us when you start rotations again in a couple of weeks?  That's going to lead to less stress?!?!  Who the hell ever heard of med school adding less stress to a person's life?  Seriously?  What are you on?  And don’t be surprised when the nerves that live with us start flashing some serious pain signals upstairs.  We can see that they're already charging their little battery like thingies in anticipation.  You may be walking funny tonight.  Again.”

            “Yeah, I know.  And as I like to say to my patients, ‘we have a pill for that’.  I’ll make whatever deal I have to make in order to keep enduring."

surgery rotation

Fortunately, my surgery rotation was not as horrendous as the videos below.  Both my attendings and residents were pretty understanding and helpful for the most part.  But I did hear some horror stories from a few of my colleagues that wouldn't be too far off from these sad but true video.  I can, however, attest to waking up at 3:40 am and grabbing AWS (already worn scrubs) and not caring because it seemed like you just left the hospital and now you're headed back.  I can also attest to holding a retractor for nearly two hours when an inanimate object could've done a better job.  And yes, they do have inanimate retractors that do a better job than med students.

Part I

medicine

     The difference in his mood, his personality, everything was in stark contrast to what it was before.  It became apparent only 2-3 days after his second hospitalization and became more and more noticeable with each passing day.  His constant anger began to lessen.  His emotional resilience, which was completely absent before, grew stronger with each passing day.  His constant tendency to fly off the handle at the smallest thing grew strangely absent.  His ability to feel and receive love returned.  And he had reversed his decision in answer to Hamlet's dilemma.  He no longer wished to sleep that endless sleep.  As my wife said, it was like getting the personality of our son back before the many years of worsening darkness.
     The difference?  Medications.  Or I should say the combination of meds as it is likely that he would not being doing as well if one of them were absent or substituted.  Stumbling onto the right permutation of meds for psychiatric illnesses is one of persistence, luck, persistence, the art of medicine, and even more persistence.  I am grateful for him finally finding the right combo to keep him alive, at least for now.  Experience tells me that this is not the end, though.  This is no cure, only a respite of unknown length.  It will be a constant battle for the rest of his life, let alone ours.

guilt

I remember when my wife was pregnant with him, people would ask us, "do you want a boy or girl?"  Both of our response was the same.  It never changed.  It never wavered.  "We just want him or her to be born healthy."
     But you don't think of the diseases that lie in wait.  Those that are not apparent from birth.  Those that are part genetic, part environmental.  A ticking time bomb waiting to go off when the wrong set of circumstances start an abnormal chain of events in the brain resulting in catastrophic and horrendous consequences.  Suicidal thoughts that are as strong as the urge to eat, if not stronger.  And as a parent, you beat yourself up over and over and over again for missing the signs.  How could I, of all people miss the signs?  But when it's your own child.......you fail to see the signposts.  At the time, they are subtle.  In retrospect, those signposts are harsh and glaring, mocking me for my failure.  You think it's teenage angst.  Or just a phase.  By the time you've got it identified, the irreparable damage has been done. 

old wounds

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.


Help, lofty genius! Muses, manifest
  Goodwill to me! Recording what befell,
  Do thou, O mind, now show thee at thy best
- Canto II from Dante's Inferno

     Without even looking at the chart, this poor young woman was college age at the oldest.  And there by her side was her younger brother.  We were consulted for essentially existential anxiety.  The patient had exhausted every option at their own hospital and were now at MD Anderson to see if they could pull a miracle.  As I sat talking, but mostly listening to her story, she began to have pain spikes.  I knew what those were all too well.  Already on a dilaudid drip and clicker on demand, she was on the best pain control possible short of putting her into a medically induced coma.  But still the pain spikes hit and during the spike her whole body would grimace and contort.  She or her brother would click the button to administer the extra medicine and wait for it to subside.  There was little medically I could do as she was receiving the best care possible.  So I held her hand and told her to squeeze it until the pain passed.  Sometimes the best thing a doctor can do is just be present and witness and honor their story and suffering. 
     The pain would pass and then she would continue telling her story with tears beginning to well up in her eyes.  She was also concerned about her mother which would cause her mother to cry.  And behind it all stood her brother unwavering.  It was all I could do to not start crying myself.  The only thing that kept me from crying was I didn't not want to intrude on their pain.  This was not about me, despite all the similarities.  It was about them and their experience.  She eventually finished her story and I reassured them that we were available to them for any help we could provide.  I walked out and waited for my resident to present to.  While waiting, the brother came out of the room to look for a coke machine.  While it was not about me, I felt that I did have something to offer the brother.  I interrupted his search and spoke to him briefly.  I told him to make sure he takes care of himself and especially his mother as they were both going through hell.  And I also gave the well used line, "and besides, how can you care for your sister if you're too broken and worn down?"
     My resident showed up shortly after and I presented to her without breaking down into tears, though my eyes did get a bit watery.  It was ok, my resident already knew my experiences with cancer (she had asked me why I seemed so comfortable around the dying patients).  There was very little we could do medically for this patient except listen.  The mother was religious so we put in a request for a chaplain.  Of course the chaplain was a familiar face from my experiences with my own brother.  Doing rounds the next day, I bumped into the chaplain and asked for his thoughts on the case.  I then bared my own experiences with him and his face went ashen.  He pulled out his card and gave it to me insisting that I contact him at some point.  I never did.  I was too busy.  Too much to do.  I wish I had taken my own advice and taken care of myself first.

relationship to pain

     Chronic pain is a difficult entity to treat.  Even if one has a purely organic cause of the pain, there are still emotions about the pain that can factor in and complicate the issue.  Pain is the relationship of your nerves, your neurology, your psyche, and your physical source of pain.  No wonder we're not good at treating it.  We simply do not understand the individual pieces of that puzzle, much less how they fit together.  I understand that stress cannot possibly not play a role in my pain.  But I am also able to predict weather fronts or a northerly breeze with a high degree of accuracy which would put a goodly portion of my pain into the organic realm and not emotional.  Whatever that relationship, it is not one I understand well.  Neither have any of the numerous doctors or physical therapists given me a sufficient explanation, much less a successful treatment.  The pain management doc went so far as to accuse me of being a drug seeker despite my not requesting any medication from them.  Being who I am, trying to understand it is important so being accused did not sit well with me.
     About the only branch with an explanation, albeit non-verifiable, is eastern medicine.  And the concept of chi is pretty ludicrous to me.  But hell, we've used medications numerous times without having a clue how they worked, or we had presumed an incorrect explanation.  Perhaps the Chinese stumbled on something millennia ago that simply works.  Their explanation doesn't have to make sense.  For me, it just has to work.  And I do get some relief from acupuncture, albeit temporary like everything else.

     Each one of these needles represents where I have, for lack of a better term, a trigger point (they continue down my right arm though you cannot see them).  These are points in the muscle that are hard, and when pressed deeply, elicit pain that extends beyond the point.  I asked the acupuncturist for the picture just for my curiosity of what the needles looked like.  When I looked at the picture, two thoughts jumped into my head, and they had nothing to do with the needles.  That part of my lower back with the four needles looks swollen.  And the upper part of my back that has 5 or 6 needles in it also looks angry.  I showed the picture to my wife, almost indignantly stating, "look at this!" feeling a need to prove that I'm not making up my pain.  It's not just stress.  Something is physically wrong with my muscles.
      "That?  Oh, your back always looks like that," she replies nonchalantly.
      "What?!?!?  Seriously???  So I'm not crazy.  I am not making this pain up."
      "Yeah, that's your back at 'normal'.  I figured you already knew that."
      In some sense, I do feel better that I'm not making this up.  It's important at this point in my life to have something make sense.  Even if only a little bit.  I shattered my right collar bone which alters the anatomy of my shoulder and my spine at that level has an extra vertebra which causes it to curve a bit to the left.  Both of these add up to a shoulder and back that have "issues", if not a proper diagnosis.  After all, my left back doesn't hurt at all.  So this simple picture helps change my relationship with the pain.  The relationship has evolved into one that is moving more towards acceptance and thinking about it less, which can only be a good thing.  I worry less about the role that stress may be playing into it and accept that it is what it is.  I accept the limitation of what my shoulder is.  Whether this acceptance alters the physicality or intensity of the pain remains to be seen (maybe, maybe not) but it is nice to know I'm not losing my mind.