29 August 2010

Damsel in Distress


Yep. Really. So…I did something really stupid. In a parking lot, after most of the other cars were gone. Instead of backing out of the space, I decided to go forward, because, hey, there’s no one else there, and why not. The front wheels hit something, started to go over it. (Well, crap). Probably another one of those little divider things in parking lots. I’ve done that before… not good…but ohwell. I keep going. And somehow, the front of the car feels higher up. And somehow, I’m stuck. The wheels are spinning, spinning, revving, I can see clouds of dust in front of me…. what the *&*&(*&^?

I get out. And. Rather than the little elongated rectangular thing I’d been picturing, it’s a sort of tree planter, diamond-shaped, probably close to a foot off the ground. Filled with sand. And, oh yeah, a tree trunk. I’m on top of it.(TO MY CREDIT. Every other such sporadic “d├ęcor” planter thing in the parking lot has a very large tree in it. Large tree. As in, in your face tree. This is the only one that doesn’t. (I look around for a wild few seconds, wondering…did I knock over a tree?”
Okay, that one’s obvious. But as to what to do next…

I didn't know what to do. After a half-hearted shove at the front bumper (yeah, right), I stood back, looking around, prepared to take another moment of * I can't believe I *&^*& did this * and then get out my insurance card and call. What else? An older gentleman, in a suit, walked from the office building to his car. He saw me, came over, and immediately looked for implements to help. I was still in disbelief-at-self mode. "Don't be upset!" he said. "I'll go get more men to help me." Key on the "men." And it's true. He found a colleague, then a third, also leaving his office at the end of the day, came to help. I realized, at some point, that they actually enjoyed this. That this perhaps was gratifying to them, as well, in doing something I had no idea how to do and could not do by myself (neither could any of them, though).The small saving grace is that the last push, which got the car, undamaged, back onto solid ground, included
me. It would have gone without me, in any case, or one of them would have leaned in more.

I may understand the concept of front-wheel drive a little bit, now, after having watched my wheels spin mercilessly and haplessly in the sand. (first introduction to the concept: "My Cousin Vinny." years ago). I don't want to be helpless in any area.
I was proud of myself when I bought brake fluid, for gods' sake. And then windshield wipers, which I changed myself after a few youtube checks. And a few more.Three times now, with
the license plates. I haven't had to change a tire (* knocks on kitchen table*), but, since I did once, successfully, with my mother when I was 14... I'm not too worried about that.



Until it seemed that the jack was bolted into my trunk, tonight. (Somehow, my 6pm saviors got it
out). Physicians can pathologize anything. Psychiatrists can pathologize any emotion, worry, stress, strain, personality quirk. They say - and maybe this is true - that those of us who choose
to be doctors do it because, this way, we think we'll never die. That if we know about bodies, things that can happen, if we can fix them for other people, we are invincible. I neither think I'm
invincible nor do I think I can fix anyone. Surgeons do that on occasion. Physicians do too, on
occasion. And mostly, we manage, try to make things a little better, slow down the course, try not to make things worse, and be there for the patient.

If I took my car into the mechanic (...which I probably should...), I give it unto their hands. I can't diagnose this. And I can be suspicious I'm being overcharged, sure, I can try to get a second opinion, but otherwise, I am clueless. I could learn if I wanted to. There are books, there are other things. It's just not a way I want to spend my time - and thus - I become more helpless and more dependent. Some people are like that with doctors. The invincible ones in the white coats. Your life, sorta, sometimes, in their hands, or at least giving you chemicals to put in your body and promising this will help, or might, or that these numbers on a little slip representing your blood mean this or that. This is wrong with you. This isn’t. This we can fix. This we can’t.
You trust. The little organ donor sticker on your license means you give doctors permission to declare you brain dead. That there is nothing left in you that can be resuscitated, that if they took you off the ventilator and maybe the dialysis machine and whatever else – or nothing – you would die. Quite simply. There is no hope for you anymore, your family will cry and sign papers, they’ll look at your driver’s license and refute it. Or hopefully not. (that’s what you thought when you signed up for the sticker, anyway). Doctors will take them into a quiet room to tell them. They’ll be allowed some moments while all of your information, the physical make-up of what used to be you (whatever you believe) is put into the computer system and UNOS will scroll across the entire country to find people sick, waiting in hospitals, at home, waiting, waiting to hear. And then you will be eviscerated. And you will save lives, so many lives, rather your body will save lives. Whatever you believe. And it is the most incredible gift. But you trust doctors for that, implicitly. Doctors pronounce death. Doctors sign life into being, that it’s * official *, that someone was actually born, on a certain day, a certain time, a certain place, and to whom. They don’t teach that, not exactly. The exam you do, yes. The steps, yes, the verification needed, yes, and what you say and how you say it to someone else. It’s supposed to come with the degree, with the license that we spend so many days over so many years to attain. There is unbelievable, incredible, humbling power in that. Even in talking, the absolute trust from patients, what they say that they may never have told anyone before. Becoming guardians of this. And trying to remember the humility, the sheer amazing-ness of it all, and how to – try to – never forget. Because everyone is human, and even in this, especially in this, there is the capacity to make mistakes.

~j

17 August 2010

Medicine....the microcosm.

This is not about Cameroon.

But I did write about medicine when I was in Cameroon. The other side. The public health side, but the hospital as well, the TB ward I wandered in and out of everyday, talking with the patients as we ate dinner on the verandah overlooking the sunset over the rainforest. (I haven't yet seroconverted). The ectopic pregnancies. The children with malaria-induced anemia who survived sometimes. The children with AIDS. The children with kwashiorkor.

The first two diagnoses I learned to make before medical school: kwashiorkor. pediatric AIDS.
In Kenya, I learned marasmus - I saw that once in Cameroon.
In Cameroon last summer, I learned Kaposi's sarcoma.
(these are not things I would learn to diagnose in the US. Not without 4 years of medical school, at least 3 years of residency, and probably a few years of fellowship).

I wrote about medicine then.

And now, I'm a third of the way into my third year. This is neither significant nor insignificant. To sum up, there are a few practical things I know how to do. (and if I was on a plane and a woman went into labor, and there was no Ob/gyn, midwife, ER doc, or 4th year med student interested in Ob, I would be slightly/somewhat competent to run the thing/do it with help). There are a few procedures I can do. There are a few things I know about, a few things I know how to treat, and a few things I can take a stab at diagnosing. Few.

But a lot of the time is spent following people, blindly, grabbing at things to learn, and being "pimped" - ie asked questions about anything at all that is somewhat related to medicine, at any time during the day, and being expected to be able to expound upon the answer.

Somehow.

Trying to be useful/being told I'm completely extraneous. Learning and doing amazing things during the day and having incredible interactions with patients - and showing up to random call in the ICU or elsewhere where there is truly nothing for me to do and no one available to facilitate that/help teach.

So that's third year. We rotate through everything and are expected to figure out what we want to do with our lives.

The question is...what if medicine, or medical school, isn't the answer?



Medicine: the microcosm.

My world has become very small. My world, in a day, is each patient, what matters to that patient, that patient's health/life in toto, and what I can do to affect that. What I know and what I don't know. I am fully present in each encounter (does this change? is that what the being jaded/disconnected means, later?) - the doctor-me. My patients, for the most part, don't have insurance. This means they don't get shit. Essentially. It means I can't refer them for things they need, they may not be able to buy/take the medications I prescribe for them, and how the hell are they going to get that many days off work to come to all these appointments, or get surgery, or whatever, if those are even options.

These are the things that make me irate, everyday, about the inequalities in health in this country, everyday, and how so many things mean, functionally, that health (and health care) becomes a privilege and not a right.

The severely depressed patients who start crying when I ask them if there is "anything else" they want to talk about, after listing all of their somatic health problems. We sit there, for a long time. We talk. (This is my luxury. As a student, I do have the time. I don't have 4-6 patients scheduled per hour). That they feel safe enough with me, that they trust me enough to tell me these things - that they may not have told anyone before - is good. It means that maybe I'll be good at this part of my job, at least.

But this happens multiple times/day, I get home, it's been 10-16 hours (or more, or a little less) of this, and I can't focus on the larger problems of the world. I'm not sure I even know what they are anymore. I can't/don't read the news, or barely. Sometimes I'll listen to BBC Global news on the commute. Sometimes. But the days are hard, mentally, physically, emotionally - especially that last part, which differentiates it from a lot of jobs/grad school that I can think of - and I don't know how much space is left for the world. I care. My "purpose" - as I needed one - to stay in the US between med school interviews and starting med school was volunteering with the Obama campaign, in Chicago. (and then going to work in Kenya). I went to NH for Kerry. I've never had a deep grasp/understanding of any of this, or any scholarly insight, or pretense to know much at all. But I still care about politics as they affect people, and as they interact around the world - knew the most in Peace Corps, probably, listening to the global news every night and discussing politics with people in my village who knew more about the European government than I ever did.

For major natural disasters - tsunami 2004, Katrina 2005, Haiti now - in the selfish sense - I get frustrated that I still have no skills, am stuck in school, and can't go where I want to be useful, and could be as more hands. But I'm in school. Now, I know there's cholera in Pakistan. (health-related, again). So i think of what I know about cholera. About what I could do, now? Doesn't register.

My world has narrowed. Science looking through the microscope. Astronomy looks through a telescope, making a microcosm of the macrocosm.

I didn't want to look through a microscope anymore. I decided not to be a scientist. I used to revel in the worlds under my eyes, at that magnification - mitochondria, open to me, most primary of organelles. Nuclei I could see imploding. And it was - is - a privilege to be let into that world, as well.

But medicine feels constricting. My view of the world, of everything, has narrowed - I see health care, inequality, the economy on a person-to-person basis - granted, it is a lot of people. And granted, on the human level is how things matter and how they are understood.
But the debates, the politics, the philosophy, the events, the turnings of things, the torments, the natural disasters - there are headlines, sometimes, but otherwise I might be months behind.

In trying to learn so much medicine, I am both forgetting other things and narrowing the scope of my new knowledge, my brain and what can fit. Only so many synapses at a time. It's gotten slower at recalling anything outside of this.
My world is narrowing, I'm a dilettante at everything else I do or try to do, and suddenly it's hard to remember what to talk about outside of medicine, health care, patients, frustrations and exhilarations in the hospital.

Medical school isn't hard. It isn't intellectually difficult (or, right now, intellectually stimulating). There's a lot of rote memorization - brute force memorization. Treatments, dosages, differentials. You have to act fast. You have to recall fast, to know everything, but you aren't, often, thinking about it. In emergent situations, at least, there isn't time. In other situations, there is, but in 15 minutes you're still supposed to take history, do a physical, decide on an assessment and plan, carry it out with the patient, write about it, and do the fifteen billing forms. And then move on.

Medical school isn't hard. Anyone could do it, once you're determined enough to get through the years and years and years of hostile hoops they set up for you. The tasks just meant to see if you have the endurance, really, to make it through. In a week of med school, we cover a semester's worth of college curriculum, in general. It's not hard. It's just fast, condensed, and focused. You have to want it to get through it and all the years of training afterward.

And to try not to let it swallow you whole.

~j