the honest man

Ever since I was a kid, I have attracted stray animals.  Dogs, cats.  Even turtles.  It seems I attract the same types of patients.  Among my colleagues, I have become notorious for being A Black Cloud.  You see, we are a highly superstitious lot.  Even more than athletes.  As one off service resident told me, it was a pleasure working with you but I NEVER want to work with you again.  One of my close friends dreads working with me again towards the end of our residency because they know what is in store.  As I work nights in the hospital and admit new patients from the ER, I hear comments from my day team colleagues who then have to deal with the aftermath of my admits.  Such comments as:

Really?  You had to pick THIS one?
Seriously?  Do you go looking for these?
WTF???
I hate you so much right now.

Even multiple attendings in clinic have asked me, don't you have any normal patients?  You know, like simple diabetes or high blood pressure.  Regular stuff.

It makes me laugh inside.  Sometimes, one laughs to keep from crying.  What else can one do?  But I continue to accumulate my menagerie of strays.  As time has passed, though, I do not simply inherently attract disasters, though I do seem to do that.  Patients share their disasters with me.  For whatever reason.  They tell me things.  They tell me things they have never told anyone else.  Honesty, has tattooed itself all over my face and patients feel comfortable telling me things that they have not told anyone.  I have accepted that role and embraced it.

i am the brute squad

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.

Some people never go crazy. What truly horrible lives they must lead.

- Charles Bukowski

"Am I going to have a call a Code Green?" the charge nurse asked, referring to a psychiatric emergency.

"Don't call a Code Green.  Call me.  I am the Code Green."  She smirked and agreed to put the patient on the floor against her better judgment as I gave her both my hospital phone number and cell phone.  My bravado, my swagger, and my humor helped sway her.

My junior resident asked me, "should I be talking to the charge nurse?"  Huh?  I was confused by the question.  But then it became clear with one statement.  "Well, I've just never seen one of my uppers talking to the charge nurse."  Seriously?  I then explain how 90% of being a good doc is simply giving a shit and getting stuff done, which means talking to all the people that get shit done. It's a lot of work but in the end, it matters.  Remember your humanity, I tell them.

This patient had been sitting in the ER for six days.  SIX days.  I was looking for admissions and the ER attending didn't sugar coat it.  I had paid my dues in the ER and earned their respect so was treated as one of their own.  The patient had broken their elbow, had surgery with pins placed which were extruding from the skin.  One pin was missing, though.  Oh, raising my eyebrow.  The patient had removed one pin by their self.  And then proceeded to attack what they thought were demons present.  So now the patient sat in the ER pending transfer to a psychiatric hospital but no one would take the patient with one extra weapon in the elbow just waiting to be unscrewed.  My junior resident looked at me as if to say, you're joking.  No wait, you're crazy.  Indeed.  I smiled back and tell the ER that we will take the patient.  Fast forward a few days of heavy duty psychiatric medications, including an episode of me, in fact, functioning as a Code Green.  Today, orthopedics removed the remaining weapon, aka pin, and the patient is pending transfer to a psychiatric hospital, without a built in weapon.  My Texas bourbon tastes extra good today.

anatomy of a call

Sunday

4:17 am
The tea kettle is singing and it's time to go camp out in the hospital.

6:46 am
After making a pit stop for caffeine and nyquil at a 24-hour pharmacy (doctors get sick, too), I'm at the hospital.  Got checkout from my colleague on all the patients and now it's time to start digging into their charts for there's always that possibility of a phone call.  So even though I've never seen any of these patients before, it's expected to know everything about them.  Hell, I expect myself to know them, regardless.

4:15 pm
Sure enough.  That call came.  And it came before rounds even started at 8 am.  "Is Mr Jones your patient?"  And 8 hours later I am called again to pronounce the patient's death.  While listening for silence, I close my eyes and I suddenly became aware of the absence of my mala beads.  So many times I rolled those well worn beads between my fingers during times of death and emotional turmoil.  The physicality of their sensation leaves a hole in my tactile senses.  But they broke.  Such is the way it goes.  I am tired but somehow my feet find their way to the chapel.  But it is not long before more calls come.  I am tired.  My body aches.  My sinuses are on fire.  And emotionally I feel an ache that is buried deep inside my bones.

writing

"In utter loneliness a writer tries to explain the inexplicable."
- John Steinbeck

"If you want to be a write, you must do two things above all: read a lot and write a lot."
- Stephen Kind


I am not sure if I want to be a writer.  But I do know that not writing leaves me with an unease.  This period of inactivity in retrospect seems a dark and useless experience.  It sits in my stomach.  Like a stone.  Which cries out to be acknowledged.  So over the next few hours, few days, few weeks, I will struggle with those inexplicable stories that I face on a near daily basis.  And write.

the power of a story

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.

The phone rang in that lull of the morning when phone calls usually do not come in.  The only calls at 3 am never portend good tidings.  This one proved no different.  It was a nurse requesting to come evaluate a patient.  There was to be no miracle for this patient, no last minute stay from the disease that had carried out its death sentence.  The pronouncement of death is one of those duties I hold sacred.  I consider it a sacrament to my profession and to my identity.  It is the final chapter a doctor can add to the story that is a patient's life.  Indeed, the final word, except for the memories that live on within the loved ones.  Still, it is rough way to begin a day.  I bow my head in reverence as I place my stethoscope upon the chest and listen for silence, bearing witness to the story that has ended.

It is now the end of the day.  Despite the fact that I am no longer in the hospital, my mood is somber, colored by the death earlier in the day.  But the last patient of the day in clinic knows nothing of this.  It is only my second time to see the patient but I remember the first visit well.  I only need look at my previous note briefly to refresh my memory.  She had come in, like all patients at some level, with a measure of suffering.  She had been to several doctors before and still felt no improvement in her suffering.  So I started at the beginning of her story.  And I did what I always do when unsure how to proceed.  I listened.  The doctors before had not listened to her story.  Instead, they ran up an enormous bill with a shotgun approach.  Had they listened, her diagnosis became clear.  Textbook, in fact, which is rarely the case for most diseases.  I pulled out my pen and added to her story by making changes to her medications.  She now sat in front of me with a smile and a thank you.  The day began with death, the final word in a story.  The day ended with a new chapter, a new sentence for a patient that reclaimed her life.

at the end

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.

Suddenly you were gone
From all the lives
You left your mark upon
I will remember....
- N. Peart

There is only now, and if now is only two days, then two days is your life and everything in it will be in proportion.  This is how you live life in two days.
- E. Hemingway


Instinctively, I turned to walk to her room.  But she was gone  Like most patients, she was only in my life but a brief time.  But in the span of a little over a week, a lifetime can be lived, or at least revisited.  It makes for an intensity in those few days that makes everyday life pale in comparison.  I had rounded on her every morning.  Medically.  And every afternoon I rounded on her.  To listen.  To say she had lived a hard life would trivialize it to a cliche.  It would also be an attempt to define one solely by what has happened to us.  As if our response was irrelevant.  Because she also lived a fascinating life.  Within her was a resilience I rarely encounter.  And also envied.  Now that she entered into this final phase, that determination to carry it through until the end became more fierce.  Death became not something to cheat or avoid.  Neither did it become something to accept and willingly embrace.  It became something to conquer.  It was as if all the slings and arrows of misfortune were culminating in one final challenge.  One final obstacle to overcome.  To prove to herself that she was indeed strong enough.

And I saw the effects of that determination ripple through her relationships of those who came to visit.  Her iron will, her pride, her self reliance.  Contrasted with those who wished to provide comfort, compassion, care.  In the face of her loved ones, I could see the hurt it caused those who would be left behind with her memories.

Indeed, it triggered my own memories of my brother.  He was not perfect.  He didn't always get the choices right.  Or, at least what I felt to be right.  But I also remember remarking on his stoic response to what life had handed him.  It allowed him to continue to fight.  And it also was an impediment in his care, especially at the end.  I imagined myself in his shoes, to the extent that one's imagination is capable of such feats.  And who is to say how any of us would handle such adversity?  Those that live in glass houses and all that.  Certainly I am not without my own regrets when faced with life and death choices.

It's not that I learned to not judge the patient's choices, though I did learn that.  It's not even a question of whether to criticize how someone copes with such choices.  Instead, it is recognizing how muddy the waters are.  That it is possible to accept and hold paradoxes true, even if for the briefest of times.  My patient was coping the best way she knew how with whatever tools that had served her in the past.  But neither does that negate the pain experienced by the loved ones at being brushed aside.  Perhaps, I wished to find fault in one party.  That would make things more palatable.  But there was none.  Everyone simply was playing the cards dealt to them.  It is a messy business, this life and loss.

final year

Courageous convictions will drag the dream into existence.

Adventures suck when you're having them.

- N. Peart

I now stand as a senior resident.  My final year of residency.  I briefly look in the rearview mirror to take it all in.  Where I started.  What I experienced.  What I have accomplished.  What I have failed.  And now standing so close to the finish line of this grand adventure that essentially started as a mid-life crisis......It truly does suck when you're in the middle of it.  And yet, and yet, it is a dream dragged kicking and screaming into existence.  Both dream and nightmare.  I am not sure I would ever want to do it again.  But I do not for a moment regret the choice I made.

gomer

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.

"So what brings you into the ER tonight?"

"I've had a cough"

Did I mention it's 4 am?

"How long?"

"Oh......probably at least for at least 10 years now."

"Has it changed at all?  Gotten any worse?  Coughing up anything?"

"Nope.  It's the same."

Did I mention that his vitals were stone cold normal?

"Any fevers, chills, weight loss, night sweats, etc, etc, etc"

"Nope.  Just the cough."

Did I mention that the patient is comfortable, calm, completely relaxed? 

"So what exactly made you come into the ER in the middle of the night?"

Did I mention this is the ER, stressing the EMERGENCY aspect of that term?

"Oh, I just thought I should get it checked out."

"And why didn't you go to a primary care doc?"

"Well, I don't like my doctor very much."

Did I mention that there are actually other SICK people in the ER?

"Do you smoke?"

"Yup"

"You, sir, likely have a smoker's cough.  Follow up with your primary care doc."

Remember this the next time someone is blathering ignorantly on about why our medical system is becoming increasingly more expensive.  Because both your and my dollars went to pay an ER triage nurse, an ER nurse, and a doc to evaluate smoker's cough at 4 am.  Never mind the infrastructure of an ER.

first, to endure

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.

My phone vibrated just as we sat down to eat.  My first weekend off in 6 weekends but by noon, I was already getting called back in to the hospital.  One of those, what I call 2-for-1 specials, came in.  In other words, a pregnant woman.  OB is one aspect of family medicine that just doesn't do it for me.  I've seen too many instances where an "uncomplicated" birth can go to a stat C-section in 5-10 minutes.  It's one of those instances where you just have to know your limitations because time means life.  For two people.

But I dragged myself back to the hospital.  Appropriately, it was raining heavily which just added to my frustrated and sleep deprived mood.  But I've learned to put that all away when with the patient.  Everything about the birth went fine.  No surprises.  No difficulties.  Perfectly routine and uninteresting which is the best kind of delivery to me.  The dad cut the cord and the parents were both joyful.  But when we asked if they had a name already picked out, the response made me stop for moment.  Josh.  I don't think I've ever delivered anyone with the same name as my brother.  No, I would remember that.  I signed the birth certificate with a sense of pride.  Probably more towards myself than anything.  I was a witness on my brother's death certificate.  And now I was the delivering doctor on this young child's birth certificate.  The words with which Hemingway signed his letters rang back through my head, "first, to endure".  I have endured.

ave atque vale

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.’

Nearly six years to the day now.  And in that six years, I have lived and experienced six lifetimes.  One thing I have learned, that experience, that life, that patients (and patience) have taught me is, I am especially in tune with the dying and suffering.  Time and time again, I gravitate towards those patients, those experiences, those opportunities to bear witness to the dying and suffering.

a good day to die

     Is there such a thing as a good death?  Or, a bad death?  Soldiers approach battle knowing full well that they may die that day.  Lakota Sioux leader Crazy Horse would exhort his soldiers with the loosely translated phrase, "let us go!  Today is a good day to die!"  But what about those dying from a chronic illness?  After bearing witness to so many dying, some had a day or two, some had months, I am convinced that there is absolutely such thing as a bad death, and if there is a bad death, there must be a good one.  I am also further convinced that dying is WORK, at least from a chronic illness.  Aside from the physical maladies, existential pain riles underneath.  Soured relationships without making amends.  What happens when I die.  What will happen to my kids.  Can you make the pain stop.  Are you sure there is nothing left to try.  What if......what if......what if......