Pain killers

The CDC has decided to "crack down" on prescription drug abuse deaths, namely painkillers. By their estimates 36,000 died from drug overdoses, "mostly prescription drugs." Ok, stat rule number 1, you have to subtract out the non prescription drug deaths. Stat rule number 2, how many of these were self harm or suicides. But let's assume that 36,000 is real which is a not trivial number. But if you read further, it's not. NEARLY 3/4 are opiates. Ok, stat rule number 3, stop rounding up to prop up your case. Facts are a bitch.  So, really it's more like 27,000 opiate overdoses, again ASSUMING suicides and non prescription drugs have been subtracted out (they haven't). But let's assume it's a real number. However, let's put that in perspective. Motor vehicle crashes kill 30-39,000 annually, depending on the year. Suicide killed over 38,000 in 2010. I don't see any public outcry for increased mental health screening in the community. I don't see any clamor for decreasing vehicle fatalities. I will wage dollars to donuts that drug addiction will remain unchanged but it will become harder for people with legitimate pain to get the relief they need. I've already watched it happen in too many patients where no one wants to give opiates to patients in the hospital who have legitimate reasons to be in severe pain. They are in the hospital after all, presumably for a real reason. I just had a patient the other day with a fractured bone that required orthopedics to put in a plate with 5 screws and the family member wanted them to get tylenol because opiates are "too dangerous". So Instead they get Tylenol or ibuprofen and the patient sufferers needlessly, not that those aren't benign drugs either. And sadly, race of the doctor and patient often plays a role.

Medical schools and residency programs formally need to make pain management an actual part of their education. I can tell you first hand that it is not. CDC crackdowns are going to be as successful as the rest of the war on drugs has been.

harshest critic

    "How do you think you're doing?" the attending asked me.  It was time for midpoint evaluations and I answered in a way that I've never done before.  I did not hesitate and responded in one word "horrible."  I then began to methodically list off all the ways I was not doing that I've always done in every other previous rotation.  If you ever need a letter of recommendation - Will make a wonderful addition to the house staff (meaning I'd be a good attending) - Will make a phenomenal doctor - Have you done this before?  These are the evaluations I am used to receiving.  But at the end of the day, they don't matter because I'm the one who has to look myself in the mirror.  My own opinion of myself has always mattered more than any one else's as long as I can remember.  Maybe I have a touch of narcissism in that regards.

    The attending agreed with my assessment but tried to be more positive and encouraging.  This is pediatrics, after all.  They're very nice people as far as rotations go, probably the nicest actually.  The attending knew enough of my story to know I was wrestling with things far beyond this hospital and asked what they could do to help.  This was my battle alone and I turned it around.  "What do you want to see from me to change my final evaluation?"

     And what the attending said will stick with me for awhile.  It's one thing to think something about yourself.  It's quite another to have a person who really doesn't know you lay it out as plain as day. 

     "You are capable of so much more.  When you are on, you are on....you are better than a lot of first year residents.  You present the patient like you're reading my mind about what I would ask next.  But there are so many times when....you're just not here.  It's like you're somewhere else.  When you're here, I need you to be here.  Does that make sense?"

Do I understand?  Absolutely.  Is that easily done?  Not a chance.

a man's got to know his limitations

*** this post is not going to make sense unless you've read this one.


"See?  Don't you remember what we said?" my extra vertebrae told me.

"Yes, I remember."

"Well, maybe you didn't learn the lessen so we're going to repeat it to you: 

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."

 

 

 

My congenital defects were right.  I pulled off both toenails.  And I was walking funny after that run.  Lest I be too stupid to accept my limitations, it's been my last run since then.  My back just can't handle it, especially since I've started rotations back up.  Pediatrics, no less.

 

"Cough, cough.  You forgot to mention that you threw out your back emptying the dishwasher and had to miss a day of work during your first week."

 

"Yes, yes, I hear you."

 

And what is it that I hear?  I'm not entirely sure.  The stress of seeing babies and kids is pure torture.  There are loving parents with perfectly healthy kids.  I will admit it.  I am jealous as hell of them.  They have a healthy kid and I don't.  Furthermore, I still may lose mine to his disease someday out of the blue.  The sword of Damocles hangs over me every hour of every day.  To drive that point home, a friend of the family lost their 23 year old daughter to suicide just a few days before Christmas.  She suffered from bipolar disease.  I know the stats and the stories all too damned well.

 

And then there are abused and neglected kids who's parents don't give a rat's ass about their kids.  Hell, probably a fourth of our admits have been what are called "social admits", meaning the kid doesn't medically need to still be in the hospital after we tidy them up but they sure as hell can't go home.  So we keep them until social work and CPS get involved.  And all the time, my gut is wrenching inside for the brokenness of this kid's life, the shattered aspect of the entire family; how the sins of the father are visited upon the son to the third and fourth generation.  They start out with three strikes against them and the cycle goes on endlessly with no hope of breaking it.  And still I will be selfish and think my son had every advantage and still is no longer himself.  So it goes.  To some questions, there are no answers.

 

So I tell my vertebrae, "I gave up sprinting.  I gave up jogging.  But I'm not giving up lifting weights," as I head to my garage to burn off the anger.

 

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.