Sunday, March 29, 2015

Never Let Them See You Sweat

I was in my third year of medical school, full of energy and drive. Typically during your first 2 years you are sitting at a desk learning from a book.  During your third year, you rotate through all of the major specialties of medicine.  Third year is your first chance to experience clinical medicine. I was on my Ob/Gyn rotation and taking 24 hour call on the labor and delivery floor.
I was on my second night of call and exhausted. "How in the world do people do this?"I thought. I had just helped deliver 2 babies and it was so busy that the attending physician, Dr. Ernest had to come in and help the residents.
    Dr. Ernest was wearing his long white coat over his dark blue scrubs; both pressed as if new. He was a short man like myself no more than 5'6'', clean shaven, with receding grey hair. Dr. Ernest, pager was going off as he zoomed by the medical student call room where I was sitting.
     "Hey, follow me, we've got a lot to do." He said quickly as I caught the corner of his eye.
I jumped up and raced after him. I was excited, this was my chance to impress an attending and better yet learn. During that night we juggled 3 complicated laboring mothers and another who needed a STAT C-section.

That night I learned a lot of clinical medicine, much of it stuck with me as I later worked through my Family Medicine residency. But one moment stuck with me and taught me an aspect of medicine that I remember to this day. We were rushing between two laboring mothers' rooms. Each almost ready to deliver. We had been working for the last 2 hours, each of us with sweat on our foreheads. Just before we walked into the patients room Dr. Ernest stopped and looked at me.
      "Look," he said as he wiped the sweat from his forehead with the arm of his white coat. "You see how busy we are? We don't even have 5 spare seconds. But I always make a point to sit in a chair next to the patient, it sends a signal to them that they are important and worth it. It seems like you have all the time in the world."

And then in a flash he shot into the room and sat in the chair next to the patient, sitting back as if he had nothing else to do. He was up again no more than a minute later after discussing the issues with the patient. But he was right, as I watched, I thought how different it would seem to the patient if their doctor stood and towered over them, checking his watch while they lay in their bed.

To this day, whenever I enter a patient's room - wherever it is. I always sit next to them. If there is no chair, I'll go get one. Or if in the hospital, I'll sit on the edge of the bed next to them. Medicine is so much more than those books you read the first two years.

Thursday, March 26, 2015

How To Get Out of Jail Free

Norman was never a patient I was proud of. He was a 21 year old with a chronic medical problem. Every time I saw him he looked as if it had been a month since his last bath and shave. And every time I saw him was to admit him to the hospital because he was not taking care of his medical condition. When that happened we had to treat him carefully and quickly or he might die. But obviously all our hard work was lost on Norman, he took all that for granted.

He even convinced a doctor in a nearby town that his medical problem was the cause of some severe chronic pain and he required large doses of pain medicines to help him.

So it wasn't any surprise to me when I opened the local paper and found that he was going to be sent to jail for selling narcotics.

A week or so later I was called down to the ER. Low and Behold it was Norman. I was amazed.
"I thought you were in jail." I asked,
"My court date is tomorrow" he responded. And I could have sworn there was a evil smile across his face.
Norman had labs abnormal enough to prove that he had to be admitted to the hospital. And all of the staff including myself felt a sense of guilt. He had to be admitted to the hospital and I felt like I was aiding him.
But I had to do my job. I admitted him and the next morning he was fine. I rushed in to the hospital hoping I could discharge him in time for his court date. As I walked into his room he was hanging up the phone.
"They pushed my court date back," he said. "By the way, I've got an appointment this morning to see the pain doctor, do you think you could hurry up my discharge."

I couldn't believe it. He was so good at the system that he took advantage of it like a master criminal. I was the lowly store clerk who could only look on as all my valuables were stolen. But he'll never be able to postpone his court date forever. In his young mind he doesn't realize that. He doesn't realize that he'll have to face up to his wrong someday. They have doctors to treat people in jail you know.

Friday, March 20, 2015

I Hope She Wins

Peggy Lillith was my next patient that morning. She was a new patient to me. She had been seeing one of my colleagues who had recently retired from our practice. As I looked at her chart prior to going into her room I realized there wasn't that much to know about her. I knew that she was 91 years old and strangely I didn't see any medical problems on her list. I mean, shouldn't all 91 year old's have at least some medical problems?

As I opened the door to her room she was sitting attentively at her chair reading a book. She had a little bit of  a tremor but she sat upright with her legs crossed. She had no glasses, her white hair combed across her head with a pin at the back. Her cheeks were pink and she had on a freshly pressed green button down shirt and khaki pants.
    "Hello Ms. Lillith, I'm Dr. Mash, It's really great to meet you." I said as way of introduction.
    Ms. Lilltih closed her book and placed it on her lap. She looked up and smiled. "Thank you Dr. Mash, I'm Peggy."
With introductions out of the way we discussed her visit that day. She was indeed very healthy. she was 91 years old and had really had no history of any medical problems. She was just there that day for a yearly check up.
I was in awe. I don't think I can remember many 91 year old's I'd ever seen without any medical problems. She was living a full life independently. She had several children that she kept talking on and on about. She still drove and did her own grocery shopping. She still spent time with friends and read books.  So I reviewed as many things as I could and made sure she didn't have any issues that might cause future problems and sent her on her way.
     "I guess I'll see you in another year," I said even surprising myself.
We shook hands and she made her way out to a lunch date she had planned with friends.

Unfortunately I heard from her several months later. She was confused and had fallen a few times the day before. She had called to make an appointment with me. I saw her in the office and she was just not the same. She was disheveled and her hair that day unkempt. Her daughter accompanied her with a worried look on her face.

I got down to business and ran labs and tests to try to figure out what had happened. Everything seemed normal except that she had a urinary tract infection. I've seen it many times. As we age, something as simple as a urinary tract infection can tip us over the edge. For her she became confused and began falling.

I placed her on antibiotics and her family agreed to make sure she stayed with them to make sure she was safe and didn't get worse. Over the next few weeks she slowly improved. But even then she just wasn't her best. It was frustrating to watch and it was even more frustrating for her, because she knew she wasn't the same. She couldn't concentrate as well and her strength wasn't as good. I had arranged for a physical therapist to come to her house and intensively help her with her balance and strength. Her family even made arrangements for a caregiver to be with her at her house 24 hours a day.

The next time I was able to see her in follow up her family was with her. She was still making slow progress towards what she was like before the infection. But still not there yet. They were all nervous because Ms. Lillith seemed so sad.
     "I just want some time to be by myself." she said frustrated, like a teenager ready to move out on her own. She was frustrated obviously because she wasn't able to live alone like before.
      "I've been alone and in charge of myself longer than anyone here, I can't understand why I have to ask permission now to go grocery shopping or go to the bathroom."

For many of us as we age our bodies come to a precipice. One false change in our system can send us over the edge, never able to climb back up. It was hard for her and her family to understand, but yes, something as simple as a urinary tract infection brought her tumbling down. She was fighting with all her might and improving each day and week. For that I am so happy. It definitely isn't out of the question that she could improve enough to go back to living alone. I really hope she wins.

Tuesday, March 17, 2015

Here are a couple pictures of one of my favorite patients a day after a big snowstorm here. I am always so inspired to see one of my elders so active. She is 91, soon to be 92. I have a good story I wrote about her, I'll post in the next week. Stay tuned.

Sunday, March 15, 2015

I Was Dead

Ms. Jenkins was an 86 year old short stocky lady. She always had a smile on her face and each time she came in to see me, even when I knew she didn't have any other plans that day, I could tell she had spent a great deal of time preparing. Her lipstick would match her shirt and shoes. And all other makeup was checked and double checked I'm sure.

She was a mother of two and when she was younger she was very successful. She and her husband ran a window cleaning business for big skyscrapers in a large city. She employed both her kids and always spoke highly of them. I think that her protective instinct followed her into retirement. She moved to be close to where her children were in our small town. She was relatively healthy but I wouldn't say she took care of her health. Each clinic visit was always a haggling session between us as to what medical treatment she would accept that time.

Then one day when I was admitting a patient in the ER there was a announcement over the radio from an ambulance on its way to us. A patient was found without a heartbeat and they were doing CPR while they were bringing her in. I took my white coat off and got ready to help out with the code. On TV codes are always so neat and tidy and miraculous. That's just not true in real life.  There is usually blood, vomit and human secretions everywhere. No one can ever find the required equipment when it is needed.

When the person was wheeled into the room, my mouth opened in horror. It was Ms. Jenkins. Her body was blue and her clothes were torn apart from the chaos of CPR. We all got started. After what seemed an eternity, with medications administered, a rhythm showed up on the EKG machine it showed that we could shock her. With plastic paddles attached one then two shocks were attempted. Then a tiny beep. And another. We all sat with mouths open in amazement this time. Her heart was beating on its own this time.

We finished off our procedures and got her ready to transfer her to a hospital with other specialists. She had turned out to have had a heart attack at home and a cardiologist had to place stents in her heart.

After she returned home her life got back to normal. She would come in often and haggle less with me about required treatments. Then about a year later, she was my last patient of the day. I had extra time and something had been nagging me about her that I felt I needed to know.

I placed my hand on her lap and asked, "Ms. Jenkins, you know you were dead. If they had found you any later you would not be here today." I paused to let what she already knew sink in. "Do you think that changed your life at all?"

Her face again was fixed to a tee, makeup perfect and shirt and pants matching. Her eyes looked up,
"You know Dr. Mash," she answered, "at first when I got home, every moment of every day was so special. Every thing I touched felt like I was touching it for the first and last time, I experienced everything like I was borrowing borrowed time."
She stopped and withdrew her hand from mine. She took a deep breath and the look on her face resembled guilt. "But then you know what, life just keeps going on. You still have your children to help, you are still just as busy as before, and you look up and you are taking things for granted again. I supposed there are people out there that cherish every moment of their lives like I used to. But I think it is just human nature for most of us to get lost in the stress of life. To forget that death is just around the corner."

Wednesday, March 11, 2015

I Can Hear You

When I round in the hospital I walk into a patients room and spend time evaluating and talking to them. Many times its early enough in the morning that the patients family members aren't there. I make a plan for the day and discuss it with the patient. Sometimes they can go home that day sometimes they aren't even close. So when we're done, I walk out of the room and in the hallways are the computers so that we can input orders and write the progress note.
Typically like clockwork, the moment I walk out of the room I hear the beep of the patients phone. They are calling their relatives. Then a pause and I hear,
        "Yeah, the doc said I could go home today!" in an excited tone.
Or, "Doc, says I have a pneumonia ..... no ... no ... I don't know let me get him..." and then a pause and a yell from the room, "Doc! come back here and talk to my daughter!"

Thursday, March 5, 2015

First Patient

When I set out to become a doctor, I thought that my goal would be to prevent death. After all, isn't that what we are taught when we are watching episodes of "house" or "ER"? So it seemed ironic that my first patient was already dead. In medical school, we are provided a cadaver to dissect, and learn all the mysteries that lie beneath the skin. This cadaver is known as our first patient. We spend countless hours with it, learning the structure and function of the human body.
For some, it is an honor to donate one's body in order for others to learn. Although I never met him in life, the person who donated his body to me and to my gross anatomy partners became someone that I spent more time with and learned more from than any other patient or teacher during medical school. All I know today about anatomy can be traced to that man. I know nothing about his life, but I know more about him and the cause of his death than he ever could have.
I prepared for my first anatomy class as well as I could. I studied as many texts as possible. I read our manual multiple times. Still, anxiety about my first class bit at my stomach the night before, like a ravenous shark tearing at its prey. I believe I could have studied for years, but I cannot think of anything that would have prepared me for seeing that dead body. Of learning how each vessel and muscle and bone fit together in that complicated work of art.
It was the first day of medical school. My classmates and I all met in the hallway minutes before class. We each had our own expectations of what lay ahead. Not just in the gross anatomy lab, but in our careers as doctors. It would all begin with our first patient, our first cadaver.
We entered through the doors of the giant anatomy lab. The air of the cooled lab room hit us like a breeze on an early morning jog. 
Ahead of us lay 28 dead bodies, all underneath white plastic covers. The room smelled of the embalming mixture used on all of the bodies to preserve them for as many weeks as we had to dissect every part of them. It was a strange smell, like a meat locker at a butchers shop, a smell that I cannot mistake to this day. Standing at the doorway, each body lay on top of silver metal tables as shiny as new kitchen appliances. Each table was aligned in a neat row, and each row, in a parallel column. All gave an initial impression of sterility that I soon learned was just a fa├žade.
We assembled around our assigned cadavers in teams of four. As we unzipped the crackling, plastic cover of the cadaver, we were opening a world that I never really imagined existed, but here it was. Our cadaver then lay before us, beckoning us to open him up and learn from his insides. This man, this dead human was lying there so still that it seemed as though he was actually concentrating on being dead. As if his concentration would break and he would suddenly sit up and laugh out loud. All of us stood silently looking at the body. It was in prone position, meaning that it was lying on its chest, with its face flattened on the dissection table and its nose bent to the left. Later, when we were finished “learning” from his back, we turned him over and his nose stayed bent, like silly putty, until we dissected it too. We knew exactly what we were supposed to do.

 Our manual read:
“Reflect the skin and superficial fascia by making the following incisions;
1. A longitudinal incision from the external occipital protuberance to the sacrum.
2. A transverse incision from the external occipital protuberance laterally along the superior nuchal line to the mastoid process.
3. A transverse incision from the spine of the seventh cervical vertebra to the acromion.
4. A transverse incision from the sacrum along the iliac crest to the iliac tubercle.
Reflect the skin and superficial facia laterally to the midaxillary line.”
I remember having to look up every single one of those words prior to that dissection in order to figure out what it meant. Basically we were creating four square shaped incisions into the back like a book to open up the back and reveal the lifeless muscles.
But it didn’t say anything about how to make an incision, or how to get up the guts to make the first cut. How hard you have to push with the scalpel to cut the thickened skin of someones back. The strange thing is that at all of the 28 other tables this same silence was taking place. Like the instant after a tragedy when the enormity of the situation comes to pass in the minds of those still alive.
Thousands of thoughts flew through my mind, and the flash of a thought about being a leader came to me. After all aren’t all doctors leaders? Isn’t that why I was trying to be a doctor? But how did one become a leader? I had no idea. Up to that point in my life I had never been a leader: Happy to follow like the wave of infantry before a battle. But I knew we couldn’t all stand there… not all 112 of us! As if a switch turned on I stopped looking at the cadaver and looked up at my partners.
     “ Could I make the first incision?” I asked hesitantly.
A waterfall of relief fell over their faces and in unison they all agreed “of course” said one, “yeah!” said another relieved. 

   The third quickly and happily handed me the scalpel. I was then left with the task of actually cutting. All of the books I read and movies of surgeries I’d ever seen looked like you would just lightly touch the surface of the skin and the anatomy would just open up like a book. They didn’t explain how thick the skin of the back is. It was as hard as cow hide. I had to push down and bear down with my body to cut deep enough into the skin and subcutaneous fat. My less than artful cuts tore the skin up and finally, mercifully, opened up to the muscles of the back. Those muscles were not shiny and red like the meat you buy at the store. The dead muscles, and the preservative used on him made those muscles gray and dull. They did not shimmer under the bright lights of the laboratory. They did not demonstrate what some of my fellow classmates would someday see in the operating room at their graceful hands. But the position of these muscles of the back were perfect and that was all we needed.
I spent months of my life in that Gross Anatomy lab with my patient and the 27 other cadavers. pouring over every muscle, nerve, artery, vein and bone over and over again. I look back on my gross anatomy class and remember vividly the moment I stayed late after a lab and suddenly realized that I was the only living person in that cold room, surrounded by 28 dead bodies. The eerie quiet was like the beginning of a horror movie. But it was the foundation of who I am as a doctor. I know all of my patients now in relation to the anatomy I learned from my first.

At the end of Gross Anatomy… at the end of all those weeks. At the end of all that work. By tradition, we had a ceremony to conclude our journey honoring those who gave their bodies to science. We each stood at our dissection table, no longer in the formalin stenched clothes, but in our normal school clothes, with our hands folded in front of ourselves in a private prayer. Our gross anatomy Professor stood at the front of the class and urged us to spend some time to think about the person that gave his body for us to respect and care for life. Strangely, I did not have an epiphany at that ceremony. I had already spent hours thinking about him in his life. Not his medical problems or what caused him to die. But how he lived and how he loved. When he was my age did he know that his remains would be inspected each muscle and bone at a time? The teaching he did for me in death would be used in my life as a doctor. Would I be able to do as much good in my lifetime as he was able to do in just those 12 short weeks? Those moments I had were not reflecting on his life, but were my time to say goodbye to a close friend. One who taught me to appreciate the life I had, and might someday help sustain others. Yes, it was strange that my first patient was dead. But I believe that my anatomy partners and I would bring good into this world because of him.