A very bad case of gastroenteritis (I won't speak of the horrors of that disease) and an impending exam tomorrow have made writing rather low on the priority this week.

i've got friends in low places

     "That'll be $1.55.  How you doing?"  Every single morning for a month it was the same.  While waiting for the attending to show up for rounds, I'd run down to the cafeteria to grab the largest iced tea possible for my source of caffeine.  And every morning, I'd reply "alright, how about yourself?"
     "Good, good," was her unwavering reply. 
     For reasons that are still unclear to me, I decided to challenge her.
     "You say you're good every morning.  Nobody can have a good day, every day."
     "I wouldn't tell ya, even if I was having a bad day.  Nuh-uh.  No sir." she replied with a mischievous grin.
     "I'm going to catch you once."
     "I'd lie to ya, even if I was having a bad day," she laughed.
     I was amazed at her willingness to engage every single person.  Was it just politeness or was it real?  One morning I decided to challenge her again because I believed her to be sincere.  When she gave her usual greeting, I replied "I ain't doing so good this morning."  And I absolutely meant it.  Hell, I hadn't been doing well the whole month.
     Sure enough, she looked sad and replied, "I'm sorry honey.  Things'll get better.  Things'll get better.  You just got to be patient and have faith."
     "Yeah, but they can get worse, too."
     "You sure right.  Uh-huh.  They CAN get worse.  And that's where you just got to keep trying."
     She was so sincere and so we played this same game for the entire month.  I got to the point where I deliberately chose her checkout line, even if it was longer.  To be quite honest, it was pretty much the highlight of my day at that particular rotation.  She showed more empathy and sincerity than many of the medical staff.  And the very last day of my rotation when I kept picking at her, she said in almost a whisper, "maybe next time I'll tell ya when I'm having a bad day."
     "Ahhh, it's my last day here for this month," I said with some disappointment.  "But I'll back at the hospital another month."
     "Alright, you can get me then."

pain

     Historical diagnosis of what afflicted a famous figure is a dicey proposition at best.  But I read of an interesting theory surrounding Ernest Hemingway's death by his own hand.  He had suffered multiple traumatic injuries leaving his body a shadow of its former self, and this from a man who was known for his daringness and bravado.  His pain left him unable to do the things he loved and that included writing.  So one theory hypothesizes, guesses really, that had medicine been able to treat pain better half a century ago, perhaps he might not have taken up that shotgun.  It's an interesting theory in that I can relate to my own life.  My physical pain has been tormenting me of late to the extent that it's limited my ability, even my desire to write.  Being in pain is exhausting.  It saps your physical energy, your emotional energy, your very will.  When I get home, my mind is not on how I want to enjoy my evening.  It's not even spent on how to make the pain go away.  It's spent on how to get the pain down to a tolerable level.  So it goes with chronic pain.  I can't remember the last time I've been pain free.  As I've said before, I have developed a very deep empathy for patients with chronic pain.  It's hard to treat and most doctors don't want to touch it or even know how to do it properly.  My family doc, fortunately, has done right by me for which I am infinitely grateful.  He tolerates a lot of my self-diagnoses (we usually agree so that helps) and experimenting with different modalities.  I can only hope that I will do the same down the road with my patients.  But it explains my lack of writing lately.

wrestling the rooster

Some times I come across other's writings that are near identical to the type of practice and doctor I wish, nay will be.

http://acountrydoctorwrites.wordpress.com/2014/01/26/wrestling-the-rooster/

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.