23 November 2010

I know the hospital well enough to walk with eyes closed.

I feel guilty. Like I'm betraying my patient, even. Giving such a nice, cheerful, engineer the diagnosis of schizophrenia. Maybe schizoaffective. Am I right? Does he have it? Yes, probably. Likely. But it feels like the kind of thing that shouldn’t happen to “people like that.” (I asked. He told me about the voices. I asked what they said. He told me). My bias. Societal bias. My judgy-ness. Societal judgy-ness. Whatever it is, it’s somewhat ingrained. It’s not that I think badly of someone who has it. I might feel sorry. I might pity. It’s a terrible label to give or to get. It’s one that doesn’t go away and one you certainly don’t want on your records, anywhere, if you’re going to be highly functional.

(but this is true of mental health diagnoses in general. Now, we’re not supposed to be denied for pre-existing conditions. We’ll see how that plays out. If it’s true – that would help eliminate/decrease one of the most unfair/unethical/immoral part-and-parcels of the health care “system” in America. (I said I wasn’t going to get political. I can’t help it. I’m incensed, everyday, over the injustices I see, everyday). There are some drugs you can hide behind. “Oh, it wasn’t for depression, it was for chronic pain. Smoking cessation. Epilepsy (harder to hide that one – epilepsy would inevitably show up, somewhere, if you had it, rather than bipolar disorder). Neuropathic pain – diabetes. What else do we prescribe them for. What else don’t we prescribe them for. Short course is easy. Maybe. Maybe).

So, the patient with schizophrenia. I’m trying to keep it that way. “With schizophrenia.” Psychiatric diagnoses – no, every diagnosis, ever pathology – is a noun. Yet we turn them into adjectives. The patient the team called “cancer girl” was the patient with cancer. “The schizophrenic patient, the bipolar patient, the dementia patient, the psychotic patient…”
The ones with, the ones with. (I’m starting to sound like the titles of a Friends episode).

It’s not just linguistics, not just semantics, to me. Giving people diagnoses as adjectives means they cannot be separated from their disease process – schizophrenic person like French person or blonde person. Yes, it’s a chronic disease – it can also be relapsing/remitting, it can be in remission – but that’s not the point. Unless a person embraces the diagnosis as part of their identity – there is a blind community, there is a deaf community, diabetes? (juvenile onset, maybe), there are groups of cancer survivors – but that still doesn’t mean people want to be identified or to identify in that way.
So it’s a shortcut. “The patient with schizophrenia” is one whole word longer than “the schizophrenic patient.” The latter, of course, becomes “the schizophrenic.” And in health care, we do “tag” people by diagnoses – it’s like a mnemonic.( I try to add to that names of loved ones, little anecdotes, home towns – small things. It’s a way in, back to the patient, in any return visit, next day, next month, next year. And it’s not just being PC or having good ‘bedside manner’ or whatever – it’s important to maintain that doctor-patient relationship in order to have a good therapeutic relationship, to work together in the treatment and prevention and management of illness and whole person).

But even at this early, early point, patients are starting to blend together in my mind. (The little tags help). People start to look alike, they have similar-ish stories, at least on the level I know, similar demographics, I’ve seen them in the same context, they’re taking the same medications, their lab values are approximately equal, we’re working on the same things…etc, etc, etc.
There will be something. The one who came in with her 23-year-old daughter with Down’s after I’d seen her for something-I-don’t-remember. The Latina woman, 40 something, with hypertension, hypercholesterolemia, diabetes… on metformin, lisinopril, hydrochlorothiazide, and simvastatin… except this one is estranged from her daughter. This one came in with her grandchildren once. This one had surgery and has a dividing scar on her abdomen.


Psychopathology is hard. It’s hard to see the ones that can’t be reversed. And that can be treated, maybe. Maybe.

I saw a patient regain a language the other day. The story is one of the ones in medicine that makes me furious, which means it involves – always – some sort of human injustice and discrimination (these are the things I argue with attending about). And I argue about with anyone in this country who does not believe that health care is a human right and that the discrepancies in health AND health care are a violation of basic precepts of fundamental humanity. I could go as far as to cite the Geneva Convention. If you get me on the topic.

Well, watch this: http://www.pbs.org/unnaturalcauses/ . That’s one thing. Food for thought. And fodder.

Not going to talk about excessive spending. About full-body CT scans. About Parkland hospital and 7 counties punting responsibilities for a county hospital onto one. About how long my patients have to wait, about people in the ER 3 days, and about the little, little I can refer people for (dental? ophtho? mental health? substance use, versus acute detox in the hospital? The patient who came in with DTs and was in the ICU for weeks? I get angry. I get incensed. And I want to write about it).

Back to my patient. Because we learn through individual stories, I think, by putting a name or a face or a particularity to a narrative and not to statistics. My patient had Hep C and subsequent fulminating cirrhosis. He was doing pretty well with medications. He’d stopped drinking, hadn’t used IV drugs in about 20 years. He came into the hospital vomiting blood*. From the liver disease, he’d developed a deficiency of clotting factors. During the hospital stay, he developed a worsening, severe headache. After a few days, they did a CT head – and it turned out that he had been bleeding, slowly, into his brain. At this point, he was obtunded, didn’t know where he was, could barely speak, and didn’t make any sense. Neurosurgery refused to take his case – to shunt, to operate, to do a spinal tap. Nothing. “He’s terminal,” they said.
After a consult from infectious disease and hepatology to say the patient was not terminal, that his bleeding diathesis could be treated, and – besides which – this immediate problem was reversible – they decided to do the procedure.

*Ok the medical facts might not make much sense because I am making them up. Altering, rather. To change the actual story, enough. The gestalt is true, though.

This is when I saw him.
That day, he only spoke Vietnamese, and I was able to communicate with him – a little – through the translator phone. He knew his name and birthday, he didn’t know he was in a hospital. (Are you in a store? a hotel? a hospital? your house?) (and…yes, this is the patient exam described at the end of the last post). Alert and oriented to…person, basically, not time or place or situation.

I returned the next day. He looked at me, smiled, and spoke in English. He started asking about when he could go home, joking about how much better the food would be there… he knew exactly where he was, why, and what would happen next. Few transfusions of clotting factors and he was okay. Otherwise healthy.

As I've heard about with stroke or with dementia, people can revert to only earlier memories, the more deeply ingrained ones. Language - there's not much more primal, urgent that is learned. He had it, sort of. And then when the pressure on his brain was relieved, he got the other one back.
I haven't seen many miracles like that.


15 November 2010

On Love and Medicine

I think a lot about “for better or for worse” these days. In medicine, you see a lot of “worse” and “worse”, and I see a lot of partners who are there for both. For anything. Siblings, children, grandchildren, nieces, nephews, friends. I guess these would be the ‘chicken soup’ or whatever stories (are they even still publishing those?) But it’s true – rushing around, where so many things are difficult and sad – it’s something to stop and think about. Or try to remember to stop and think about. With the sickest patients, it’s their loved ones that I know. The ICU patients, the altered mental status patients, dementia, kids…whatever. I’ve spoken with a lot of family members. In anesthesia, wheeling people into surgery, you leave Loved Ones at the corner. (They call it the ‘kissing corner.’ Really). And you see them into the waiting room, point it out, say go get coffee or whatever, we’ll be ____ hours, and don’t worry, we’ll take really good care of X. Your X. I’ve seen the wide eyes when we push through the doors again, X is barely waking up from surgery, likely has an oxygen mask over her face, and we’re rushing into the PACU. It doesn’t mean anything’s wrong. It’s normal, and it means the surgery’s over, and if people don’t look like they’re freaking out (The doctors), everything is probably fine. It’s a vulnerable position to see someone in. And in the OR, they’re alone.

There’s the couple who came in with the wife’s entire medical history typed out – each had their own version – with a list of questions. She suddenly went blind, no one has any idea why, no one has any idea if it’s part of something more progressive – probably. So they’re searching. And with each doctor, they get more frustrated at not having answers. But the other point, to me, is that it’s always both, it’s really about their health, and the patient is – almost – both. Making sure you do speak to both.

There was the man whose wife died of ALS (Lou Gehrig’s disease). She lived with it for twelve years, far longer than the average prognosis. At the end she was, as they are, completely paralyzed, ventilator-dependent, and could not speak or do anything independently. He ran marathons with her – there were photos of the special chair he ran with. For ALS research. There were vacations…. everything you can imagine that is so hard to imagine in those circumstances. So when she died, he wanted to donate all of her special equipment (hundreds of thousands of dollars, I think), some of which he had designed or modified, to other patients. He drove across the country with this. He’s still working with ALS.

And there’s the patient who had a second stroke on top of her first one and was almost comatose. Before the second one, she and her husband had been living with their daughter, just while she was doing rehab. He kept trying to convince us – again, again, again – that she was fine, that they could go back to their own home. They’d been together over 60 years. All he wanted was to take her home. And then there was the second stroke, and she wasn’t talking but I saw him every day, the daughter, the granddaughters. He left to get food sometimes, when his daughter was around. Otherwise.

There is love in medicine. And it’s the patients who don’t seem to have that support who are the hardest, for me. Almost doesn’t matter what the diagnosis is. When you can’t send a patient home because there’s no one to help, there, or the people there will not help… it’s hard. And it does change the medical plan. It’s been gratifying to me to realize how much this is taken into account. Teams don’t – or try not to, anyway – discharge patients without knowing where they’re going, and how. (and yes, then they pawn the patient off onto a social worker. but that’s why everyone is expert at different things).

But medicine has to be a little bit about love. It has to be about healing. When we’re in surgery waiting for pathology to call back – cancer or not cancer – everyone is holding their breaths, a little bit. Everyone wants to know what is finally said. And yes, people get jaded when they are overworked and overtired and it’s overwhelming to care individually about every single person in a day that you’re caring for, and if you’re in the hospital, some of them will die. I’ve heard  people comment about the annoying paperwork of death certificates, rolling up the sheets (like we do with everything else) and sticking them into a pocket. Everyone’s job has lots of paperwork and bureaucracy. In this job, the papers can say things like “full code/do not resuscitate/ do not intubate.” A progress note can describe a scene of death, at what time, what exactly happened, who was there. And it can also describe a birth – clinically, the first moments of someone’s life, and not just that but exactly what happened before. And who was there. And what happened. It’s a little bit of personal history before the lungs are even shocked into expanding and the fetal vessel connections close, and, and….

This is our bureaucracy. This is our paperwork. Birth, death, prescriptions, and “orders.” And “progress notes.” And more “orders.”
To me, it’s a heady thing to decide how much pain medication to give someone – what drug, how much of it, how often can they take it, and how many (the decisions are often left up to me, with the attending shrugging “sure!”. Then the attending signs the prescription I’ve pre-written). I write admission notes and orders, and yes, everything I do gets co-signed, but not every resident is going to re-read every line. I wrote out the medications and dosages. It seems like a small thing, maybe. But from my scrawled handwriting, faxed to the nurse’s station, to the patient’s chart, to the pharmacy… I’ve decided something, I might have changed it, I might have screwed it up. I decide a lot of things for patients, now, and as long as it’s a “fine” idea, it generally gets signed. There are a lot of choices, a lot of not-right/not-wrongs, and it can be unnerving. For another patient, her subspecialty doctor decided to proceed to surgery for her rather than medical management – based partly on my exam. My exam which had not been verified, up to that point, but done and recorded by me. I was terrified of this responsibility until we went to the other specialist who confirmed my exact findings. I wasn’t wrong. But I could have been. Easily. (and residents are, too. and attending are. this happens). There are so few things directly in my control, currently, that each thing that is can be terrifying. Shattering. What if I’m wrong. I’m in no life-or-death position, yet. Yet. It’s really not very far away.


Another patient hugged me today.

I’m not exactly sure why. I told her nothing was abnormal with her on my exam – which sometimes, under the circumstances of having annoying/uncomfortable symptoms – I would think would be frustrating to hear. Apparently, she had been worried about “something wrong”, however, even though she hadn’t said it. And so she hugged me.
This was in urgent care – we hadn’t talked for more than 10 minutes, my whole exam was five, then 2? 3? discussing results and giving her a prescription.
And she hugged me.

Another patient today, when he started discussing serious depression (this is not in psych clinic) said “wow, I’ve never talked about this with anyone before…”
I get that a lot.
And it sure as heck is ego-boosting.

Is it true? Who knows. Yes, probably. But it’s the white coat, the concerned look, leaning forward, attentive body posture, language (is it true? Yes……is it true every minute? …no). I am listening, caring, I am making notes. I’m also conscious of what I’m doing, though it is becoming fairly ingrained. (And I have an agenda, and questions I want to make sure I get to, I have a time frame, and I do have to redirect and interrupt). It’s not anything anyone can’t do. The mistake people make sometimes is forgetting all the human skills they already have, had before medical school. The best, most rewarding, most meaningful things I have managed to do, have, for the most part, drawn upon things I’ve had for years.
And maybe I’m more comfortable now than I was pre-med school in discussing difficult topics.

I’ve got the… license to do it (technically speaking, 1/3 medical license). I have gone through all these years and still am going through them in order to be…trusted? Trustworthy? Organic chemistry certainly didn’t make me that way.

I am engaged in each encounter. I try to be. But there’s also the walking briskly down the halls, always, around people in the hospital, looking busy-and-important. And trying to read my watch while a patient goes on and on and on because I’m going to be late for rounds and I still have to write down the vitals and the labs and do my assessment and plan and I have to present and I’m already supposed to be on the 9th floor and I keep interrupting anyway but…


In a hospital (this isn’t true of all of them) with widespread, good, easy-to-access wi-fi and cell service, I walk down the hall reading and answering email (thank you, ipod touch, and medical school that requires PDAs in the third year, and younger sister with a job and a penchant for buying the latest gadgets and sending the older ones to me…). I know where I’m going and I don’t need to look. I can do this at the same time, and I’m not wasting time. I’ve walked down the hall writing progress notes, before. It saves time. Today, between 7 am and 4:30 pm, I found 5 minutes in which I could – between dropping off orders on the second floor and running back to meet my resident in the ER – sit for 5 minutes and have cereal left in the resident lounge.
(This is a sometimes-but-not-always-necessary occurrence. As is the 4.5 hours of sleep – some things are self-inflicted, as I sit writing this rather than reviewing current guidelines for opportunistic infection prophylaxis, adrenocortical insufficiency and leukocytosis, or TIMI scores. Or differentials of syncope and alcoholism and dehydration. Or bullous pemphigoid. Or altered mental status.)
But I digress. AGAIN.

Here is an interesting exercise. “What is your name?” Correct answer. “How old are you?” Correct answer.
 “What is the date?” Confused mutterings, similar to “what is the day?” and “where are you?” This is where, in psych, we start in with choices. (Psych or neuro. same diff). “Okay. Are you in a store? A hotel? A hospital? your house?” Still no answer. I think maybe next time I’ll make it more interesting and add zoo or something…. heck, I have a friend whose grandmother had Alzheimer’s and lived in a delusional world that consisted of a perpetual cruise ship. Not bad, as far as delusions go).
Yet – the patient knew – “What city are we in?” “What state?” and “Who is the president?”

The things we retain.


03 November 2010

I used to do this to fruit flies, and sometimes I forgot*

I’m in anesthesia now (the rotation1). It’s alternately seen as the your-patients-are-asleep specialty, the knock-them-out-quickly specialty, the bring-people-close-to-death specialty, the more-drug-addicts-than-any-other specialty, the control-the-level-of-consciousness specialty, and, as one resident said to me, the anti-death specialty.

It is surreal. Which is more like playing god? The sterile, scrubbed, blue-gowned ones on the body cavity side of the blue-sterile curtain (now: blue equates to sterile. It does in the OR. Synonymous), the ones who are cutting through skin – the ultimate violation – and putting their hands in and manipulating another person’s internal organs.
Or. The ones on the non-sterile side of the blue curtain, the head side (usually), who put a tube down that person’s throat and connect it to a machine to breathe for them, who tightly control drugs (by feel, actually, more than by dosage) to keep them awake/not in pain/not remembering/not alive/not. Yes, the machine plugged into the wall is playing god2.

You’re going to go to sleep soon, I tell the patient. You’re not going to remember any of this.
And they don’t.

1(Though – note on that – dinner with friends the other night. Friend of Y’s showed up, and Y asked me something along the lines of “didn’t you have anesthesia today?” or “weren’t you on anesthesia today?” Her friend looked at me kinda funny… I guess I looked fairly alert for someone he presumed to have recently had surgery. I raised my glass at him. “AND then I drove over here!” Oh, medicine….)

2 Being a skeptic, I may overuse this phrase to the point of meaninglessness. Apologies.

*(to take them out of the freezer). I’d take them home sometimes … forget exactly what I did to them there, separated them, maybe I could tell wing shape or color or what have you. And the way you anesthetize them to get them to stop moving is to put them in the freezer. Quick and dirty. And yes, sometimes, I forgot to take them out. In the lab, in college (freezer was high school experiments – maybe it was just taking them home to babysit as no one would watch them over the weekend?) we used CO2 to put them to sleep. And sometimes you use too much. And it’s fruit flies, which, though they have taught us so much of what we know about genetics, we can shrug over and move on. It’s a 10 day reproductive cycle. Born to reproduce. More or less, cross them again, again, again.

Today I put (read: rammed carefully and deliberately) a tube down a woman’s throat to help her breathe. Successfully.
For the sake of argument, I’m going to compare myself to Obama for a moment (because… well that’s nice).

The woman had a disease, not life-threatening at all, a little uncomfortable, and she came in for elective (doesn’t mean, like, plastic. Just means it was planned and not emergency surgery) surgery. She’s basically very healthy. People out of my control and out of her control started to give her drugs through her IV:
one to make you feel like you’ve had a few too many cocktails (Versed/midazolam)
one that is numbing medicine (lidocaine)
one that will sting a little. This one will put you to sleep (Propofol)
and one that will help with pain (fentanyl).

All together, they depress her drive to breathe. She is no longer able to breathe on her own; her brain can’t interpret the signals that she’s filling up with CO2. Now, these people/actors on the economy… are not totally malicious. Before giving the drugs to make her go to sleep, they put an oxygen mask (tight, uncomfortable, pressed down) over her mouth and nose and have her take deep breaths of oxygen. This too makes her light-headed and sleepy.

And as soon as she’s out. “Ms X? Ms X?” Touch her eyelids. “Open your eyes, Ms. X.” Nada.

And Obama enters the office and tries to do something for…the economy. Everything.

The mask stays on awhile longer. I’m holding it as tight as I can – harder than it sounds – gripping under her jaw bone and thrusting her chin up. Forcing oxygen through a balloon into her lungs. But I can’t do this forever. It’s a several hour surgery. I’ll get tired. My hand could – and will – slip from the mask, from the balloon, over this period of time. Besides which, we have millions of dollars of machines next to me, beeping.
 Then -
The mask comes off. And out come the instruments to ram down her throat. I look. Try not to break her teeth as I pull UP with the laryngoscope, finally see the vocal cords, and thread the tube down them. I attach the oxygen to the tube now jutting out of her throat and continue to squeeze in air, for awhile, while we check it’s in her trachea and not in her esophagus (… as it was the first two times I tried this week. Oxygen to stomach? Not. Helpful). And then I flip the big switch to the ventilator and the accordion does my job – up, down – and the people who put her to sleep and paralyzed her and made her stop breathing in the first place add inhaled anesthetic to the oxygen. Keep her drugged.

Paralyzed. Unable to breathe. And I help by placing a tube in her throat at this time.
There’s nothing more helpful to do, yet.

And sedation?
American voting public, perhaps.
My resident was confused about why I asked to come in late so that I could vote (ie, polls open at 7, can’t get to the OR at 6:30). In planning for the next day, he said, “oh, yeah, you’ll be coming in later because of your “voting thing.” Yup, it’s pretty kooky of me to want to vote on election day. Very original idea.

Change parties, cause, yeah, it takes time and work to revive someone brought to the brink of death and paralysis (making someone not be able to breathe or move?) Long-term and short-term.

And/or sedation to not caring.

Politics. Medicine. And it’s November, so there are words flying….everywhere.


01 November 2010

The Importance of Letters and Light

In brief. Before we take off on 30 days and nights of literary abandon (NaNoWriMo.org , thanks for that phrasing and the Office of Letters and Light reference), something on the importance of writing. Writing is important. (and..done). In science, I fight the stereotype that it's not. That literature's not serious. That pursuits of the arts arenot (as) important. That "easier" physics is "physics for poets." The easy, blow-off majors. Can't be serious if it requires fewer credits (college) and doesn't include hours drudging in chemistry labs among fumes and uncomfortable metals stools. 

Writers change the world, too. Writers dictate what we know about the world, everything that we cannot directly ascertain for ourselves (which is most things). Speechwriters, copy writers, editors, blog writers, journalists (obviously) - influence. Everything. I was influenced in no-small-way to work with the Obama campaign, to go to Chicago, after reading Dreams from My Father. In medicine, every single thing we do with a patient, we talk about, must be documented. Is written down.

But that's "non-fiction", if such a thing, complete objectivity, exists.

(even in medicine - it's fascinating, reading through a patient's record, to see how the past medical history/family history/social history "changes." As in, that particular writer asked different/more questions, didn't ask/wasn't paying attention, or the patient said something completely different. )

Sumerians, Hammurabi, hieroglyphs, Rosetta stone.

But fiction changes the world, too. It's how we learn about different cultures, different ideas, different times - stories, personal ones, are what make things poignant. Make them stick. In getting into a character's head, you start to understand - something - else. It changes the reader and it changes the writer. And poetry? Poems are listening, seeing, paying attention in a different kind of way, and trying to connect with a human experience. Reading and writing. The ether, the Jungian collective consciousness. To write more about poetry, I really need to reread Plato.
But I digress.

Whatever it is you write, fiction/not, 50,000 words/not, handwritten, typed, online, in a letter, in an email. it's important, it's November, so - write.:)