25 February 2011

…And back to the original precept of “medicine: the microcosm.”

The Middle East is exploding – maybe to long-term good, at least in the countries with more peaceful revolutions. Vocalizing freedom, enacting change, moving toward a more internally-designed governing system. Hopefully. Then there’s Libya… it’s still hard to have personal, visceral reactions to things when announced in numbers and not names. If one of them was my patient. If one of my patients had family there.
But as much as I – when I remember – try to remain engaged with the world in, at least, a passive way, I have no idea what’s going on.

How do I know that California (one part of the country not ever really in winter?) is expecting snow tomorrow, for the first time in 30ish years? Patients. Same way I knew it was going to be in the 60s last weekend – a patient was preparing for a trip to New York.

23 February 2011

Words we use with kids

Toxic. Non-toxic.
(sick/not sick)
(kid with cystic fibrosis).
(Kid with cancer).
FTT: Failure to Thrive
(losing weight/not gaining weight, either from chronic disease or from neglect)
(going quickly downhill/possible to death)

Two kids I saw in the office, who were completely fine.

Baby L. Perfect newborn exam. Perfect. Slight ductus arteriosus, I think, that was closing. Breastfeeding was going well. Mom had 4 other kids at home, lots of social stressors, but her husband was involved, there was a grandmother somewhere, and maybe one of the older kids was around to help out, too. History of post-partum depression and chronic mental health issues – we talked about that – but doing well, couldn’t take meds during pregnancy but on top of her symptoms. In touch with a social worker.
Minor issue – her 20 month old son had a cold.
Well, try to keep her away from the new baby.
(easier said than done. Baby wants attention away from the new baby).
Sunday, I was in the ER, and I glanced over at the list of patients admitted the previous day. Baby L was on there. And Baby L was in the Pediatric ICU (PICU).
I had seen Baby L in the office on Thursday, I think, and the attending had seen her as well. Doing beautifully, as they say, with the requisite “congratulations!” and “what a cute baby!” “what a perfect baby!” Baby L was doing fine.
…and then Baby L caught RSV* from big brother. And Baby L started having apneic episodes, when she stopped breathing. And Baby L came in by ambulance and was in the ICU hooked up to monitors, now.

*respiratory syncytial virus. In adults, it’s almost asymptomatic. In a number of toddlers, too. But some of the ones who get sick, and some of the babies…get sick fast. There’s no treatment.

15 February 2011

Reading palms

I spend most of my day touching people.

My patients might grasp my freshly alcohol-gelled hand when I offer it, walking into the room. And they might be too nervous or distracted. And they might be the ones who, overwhelmed, hug me before leaving (I’ve stopped counting those). And yet I touch them…everywhere. In that sense, nothing is sacred; but in the other sense, everything is.

Some doctors put on gloves for the entire exam.
I don’t.

I’ve learned both ways, and now, we choose things. It’s a mixture of universal precautions and respect – always, always gloves for any genital exam; always, always gloves when touching anything with secretions. A rash. The inside of the mouth. Anything bleeding or with pus. Anywhere the skin might be broken.
Otherwise, I wash my hands two to four times per patient visit. (Once outside the room. Once inside, prior to the physical exam. Perhaps once after, before leaving the room. And then maybe again in the hallway.)

Recently, I had a patient whose arm was in a cast. After a week, he suddenly spiked a fever and started to feel pain in his arm, which he hadn’t before. Common things being common, if you hear hoof beats think horses, not zebras (the platitudes of medicine), it’s probably a bread-and-butter pediatrics case. I.e., cold. Flu. But it could be something else, something we can’t see.
It felt like black box medicine. Diagnosing without seeing what you might be trying to either diagnose or rule out. What are the proxies. How can we see without seeing, know without knowing. The fingertips were visible – warm, well-perfused, good capillary refill, pulses intact bilaterally, sensation within normal limits. Nerves, vessels intact.
Then to the proximal side – the side closer to the body. I touched the arm above the cast. I touched the other arm in the same place. Cooler. Again. Both hands simultaneously. Switching hands. One hand at a time. I closed my eyes, trying to feel the temperature difference. There was one. It was subtle. But how subtle is subtle, and how warm is just from being enclosed in fiberglass?

08 February 2011

Standing Room Only

Zen, Part 2

 (Trigeminal nerve, CN V1,2,3: Superior orbital fissure, foramen Rotundum, foramen Ovale. SRO).
 (Single room occupancy; marginal/subsidized city housing. SRO).

It had been on my calendar for months.Historic bookstore (in the sense of..literary history). Reading. Writers recently published in The New Yorker. Including a physician-writer, Chris Adrian. Introduced by Deborah Treisman.

Nothing imperfect.

We arrived – less early than I would have liked, but still with plenty of time – and there was almost no one milling about the stacks. It was quiet. I thought we had time. Walking slowly through the store – there must have been time to savour it – I saw a group of four chatting in a corner. The writers. I knew only because I recognized the events coordinator. The writers. But where was the reading? I’d never been to one here before. We walked to the back of the store, to the stairs – and there was the line. The reading was upstairs. And the line was all the way down the stairs – two to a stair, leaning against the wall, ready to rush up and into each other when the words started to float down. So everyone could hear. We assumed that if everyone was lined up here, it must be backed up to… I had no idea how big the room was. How many people might have been in there. And whom. All I knew was that the writers weren’t, not yet, until they passed us, single-file, along the stairs.

01 February 2011

Where it is located

I’ve realized, again, that the lower back is the genesis of much movement in African dance. It’s the center, the core in a different sense than is described in Western forms of dance (the Western “core”, at least from what I’ve heard/been taught, focuses more on the anterior, the abdomen). It’s the center of gravity if you’re bending back, held up to the sun with an invisible force, giving homage with joy to everything above and around.

It’s different.

If you’ve been to Africa, backs – particularly women’s backs – look different. And this is why. Somehow (and I haven’t identified this, anatomically) these are muscles that aren’t used as much in other parts of the world.

It’s more than standing tall, proud, unadorned.
It’s carrying a bucket of water on your head, touching lightly with fingertips on one side.
Not swaying. Not spilling any.
It’s doing the same with laundry, régimes of plantains, furniture.
It’s walking back from the fields with the woven basket on your back, tied around your arms with the two lengths of fabric. Machete hanging out behind, probably, with the plantains and manioc and arachides.
It’s carrying children there. The crook not of an elbow, but of a back. Shifting on the hip sways you to one side – it’s uneven, it’s not ergonomic. It’s not long-term. You – they – can walk forever with the child cradled there, just so, tied in a pagne.
It’s the classical pose of the drummer reaching for the sky, pausing between tam-tam beats.
It’s the wooden statue of a women with a water jug on her head.
It’s the machete raised high overhead to reap plantains and papayas and coconuts and palm fronds and avocadoes and…