It usually happens after missed sleep. Whether it be the children or a night on call. The first sensation is a an awkward unease. A strange feeling in my eyes.
As my vision skews my mind races to the likely possibility of another headache. I look straight ahead. Lines? Images blur as letters disappear from words. Out of the corner of my right eye... pulsating. Like a disco ball or blinking light whose intensity varies by from second to second. Lightning flashes in and out of my visual field. There is no pain yet. Just the dull, obnoxious feeling...adrift.
By now inevitability. The fear is replaced by resolve. I mentally calculate. How much work is left in the day? How long in the car? I ransack the office for Tylenol. Ibuprofen. If I can I take two of both. As the visual symptoms fade I get ready for the numbing pain.
I used to take triptans but not so much lately. Usually the otc's help enough.
I continue work.....or whatever I am doing. But in slow motion. Like operating underwater...in a fog. As if I had been hit on the head with a baseball bat. The original thud didn't kill me....but a dull, pulsating, heaviness affects my every movement. My every thought.
And I wait helpless. Till the pain goes away. Till the day ends. Till I am lucky enough..... to fall asleep.
Sunday, November 28, 2010
Saturday, November 27, 2010
They Are All Code Blue Now
"Code Blue ICU....Code Blue ICU"
I was greeted by the PA system as I walked into the hospital this morning. A shiver ran down my spine as I quickened my pace . The days of running to codes are long gone. But since I have a patient In the ICU I was curious and just a little bit worried.
As I walked through the sliding doors I passed the room full of doctors and nurses frantically working. It was not my patient. The ICU doctor stood on the side calmly directing the measured chaos.
And my mind wandered back to my training. As a second year resident I was on call at at VA hospital every fourth night. left alone with a few unseasoned interns and hundreds of ill patients I was the head of the show.
And our patients crashed and burned on a regular basis. One...Two...sometimes four codes in one night. Although it was the beginning of my medical career I was used to it...each of us residents a veteran of hundreds of codes already.
I would stand at the head of the bed. Directing the CPR, medications, Line insertions, and intubations. Some of our patients lived. Some of them died.
We felt like doctors. real doctors. Like the ones on TV....swooping in at the last minute to save the day as family members knelt at our feet in gracious thanks (well not exactly).
But eventually I graduated residency. I became an attending and practiced in the real world...unshielded by academic hierarchy. I was rarely in the hospital when my patients coded. The ICU, nurses, and rapid response teams took over. And the decision process changed.
I still make decisions that alter people's lives. They may not be as dramatic. I no longer pull out the paddles and shock their chest when the monitor starts to buzz. My decisions are much more mundane. To change the medicines. To order the cat scan. To offer hospice.
Much less glamorous. But still fraught with consequences. I may sleep more then I did during residency.
But probably a lot less soundly.
I was greeted by the PA system as I walked into the hospital this morning. A shiver ran down my spine as I quickened my pace . The days of running to codes are long gone. But since I have a patient In the ICU I was curious and just a little bit worried.
As I walked through the sliding doors I passed the room full of doctors and nurses frantically working. It was not my patient. The ICU doctor stood on the side calmly directing the measured chaos.
And my mind wandered back to my training. As a second year resident I was on call at at VA hospital every fourth night. left alone with a few unseasoned interns and hundreds of ill patients I was the head of the show.
And our patients crashed and burned on a regular basis. One...Two...sometimes four codes in one night. Although it was the beginning of my medical career I was used to it...each of us residents a veteran of hundreds of codes already.
I would stand at the head of the bed. Directing the CPR, medications, Line insertions, and intubations. Some of our patients lived. Some of them died.
We felt like doctors. real doctors. Like the ones on TV....swooping in at the last minute to save the day as family members knelt at our feet in gracious thanks (well not exactly).
But eventually I graduated residency. I became an attending and practiced in the real world...unshielded by academic hierarchy. I was rarely in the hospital when my patients coded. The ICU, nurses, and rapid response teams took over. And the decision process changed.
I still make decisions that alter people's lives. They may not be as dramatic. I no longer pull out the paddles and shock their chest when the monitor starts to buzz. My decisions are much more mundane. To change the medicines. To order the cat scan. To offer hospice.
Much less glamorous. But still fraught with consequences. I may sleep more then I did during residency.
But probably a lot less soundly.
Wednesday, November 24, 2010
Portraits Of The City 3
The sound was electric. A kind of whirring. The silver faced man with top hat and black jump suit had elbow and knee pads. He moved mechanically in fits and starts. The crowd swayed as the wind blew on a cold fall day. The performer was jacket less. All exposed skin was painted metallic. His face stood still like a mask and betrayed his bodily movements.
Michael Jackson's thriller blared in the background. A meager holiday season, passer buys were more interested in the live entertainment then the big box store that was being ignored in the background.
A small hat sat to the side and a thin man without a coat waited on a bucket turned over. He held the radio close to his body. He watched his counterpart stand on a brick ledge. He kept an eye on the stray quarter or dollar bill that found its way into the meek surroundings of felt and fabric.
A large clerk exploded out of the store. He pushed through the crowd to the front. His arms bare underneath the logoed short sleeve shirt he was no doubt forced to wear. As he emerged the thin man sitting on the bucket jumped up and placed himself between the performer and the clerk.
Even in the cold the clerk had sweat running down his side burns. Heated arguments ensued. The clerk trying to move the crowd away from blocking the store entrance. The performer's keeper fighting for a few inches of turf in this industrialized, consumer jungle.
And the man with the silver face continued to move with mechanical accuracy. The radio drowned out the sounds of the characters arguing. And another Michael Jackson song began to play:
Michael Jackson's thriller blared in the background. A meager holiday season, passer buys were more interested in the live entertainment then the big box store that was being ignored in the background.
A small hat sat to the side and a thin man without a coat waited on a bucket turned over. He held the radio close to his body. He watched his counterpart stand on a brick ledge. He kept an eye on the stray quarter or dollar bill that found its way into the meek surroundings of felt and fabric.
A large clerk exploded out of the store. He pushed through the crowd to the front. His arms bare underneath the logoed short sleeve shirt he was no doubt forced to wear. As he emerged the thin man sitting on the bucket jumped up and placed himself between the performer and the clerk.
Even in the cold the clerk had sweat running down his side burns. Heated arguments ensued. The clerk trying to move the crowd away from blocking the store entrance. The performer's keeper fighting for a few inches of turf in this industrialized, consumer jungle.
And the man with the silver face continued to move with mechanical accuracy. The radio drowned out the sounds of the characters arguing. And another Michael Jackson song began to play:
They told him don't you ever come around here
Don't want to see your face, you better disappear
The fire's in their eyes and their words are really clear
So beat it, just beat it
Tuesday, November 23, 2010
Ah,,,,The Holidays
Something happens the last three months of the year. Every year. It's like clockwork....our lives go haywire. Instead of happiness the holidays bring pain and suffering, malevolence and discontent, and oh ya.....plain old anger. It's a frustrating time to be a physician.
The old people die.
Every year during the holidays. In droves. Inexplicably. Out of nowhere. One or two a week. Sometimes after long periods of suffering. Sometimes, all of the sudden, to every one's surprise. In greater numbers then in all the other months of the year.
The middle aged and chronically ill get depressed.
Highly functioning people become psychotic. As if something threw them over the edge or under the bus. Mental status change is the complaint of the day until it is dethroned by inexplicable pain. All over the body. Immune to the foraging fingers of cat scans and mri's. Resistant to even the most obscure blood tests. Antidepressants are dispensed like life saving oxygen.
The young get mad.
Mad that they feel unease. Mad at our busy schedules. Mad that illness is a resistant and often obnoxious foe that doesn't always bend to the will of the hapless physician. So they yell, and scream, and threaten.....as turkeys bake, carollers sing, and snow carpets the land.
And we....the downtrodden and tired. Beleaguered and feeling abused. Bundle up against the cold ice ridden world. And hunker down.
For whatever comes next.
The old people die.
Every year during the holidays. In droves. Inexplicably. Out of nowhere. One or two a week. Sometimes after long periods of suffering. Sometimes, all of the sudden, to every one's surprise. In greater numbers then in all the other months of the year.
The middle aged and chronically ill get depressed.
Highly functioning people become psychotic. As if something threw them over the edge or under the bus. Mental status change is the complaint of the day until it is dethroned by inexplicable pain. All over the body. Immune to the foraging fingers of cat scans and mri's. Resistant to even the most obscure blood tests. Antidepressants are dispensed like life saving oxygen.
The young get mad.
Mad that they feel unease. Mad at our busy schedules. Mad that illness is a resistant and often obnoxious foe that doesn't always bend to the will of the hapless physician. So they yell, and scream, and threaten.....as turkeys bake, carollers sing, and snow carpets the land.
And we....the downtrodden and tired. Beleaguered and feeling abused. Bundle up against the cold ice ridden world. And hunker down.
For whatever comes next.
Monday, November 22, 2010
The Truth Is...I love Internal Medicine
I have spent a lot of time on this blog describing what bothers me about being a primary care practitioner. And while this is all true...I love Internal Medicine.
I love being the first one to evaluate a medical problem.
I love using detective work and Occam's Razor to take a complicated story and develop a unified and cohesive diagnosis and treatment plan.
I love using all my senses to treat medical illness. To listen, to touch, to see...being a good internist takes all of them.
I love forming long standing relationships with my patients. Getting to know their children...and grandchildren...and sometimes great grandchildren.
I love catching a diagnosis that everyone else has missed.
I became an Internist because I felt it was the most rounded, challenging, intellectual prospect in all of medicine. As my role in this medical system becomes denigrated, marginalized, and abandoned...
I wonder If I will love it as much.
I love being the first one to evaluate a medical problem.
I love using detective work and Occam's Razor to take a complicated story and develop a unified and cohesive diagnosis and treatment plan.
I love using all my senses to treat medical illness. To listen, to touch, to see...being a good internist takes all of them.
I love forming long standing relationships with my patients. Getting to know their children...and grandchildren...and sometimes great grandchildren.
I love catching a diagnosis that everyone else has missed.
I became an Internist because I felt it was the most rounded, challenging, intellectual prospect in all of medicine. As my role in this medical system becomes denigrated, marginalized, and abandoned...
I wonder If I will love it as much.
Sunday, November 21, 2010
Memories of College
It was the beginning of a new school year. I had just gotten out of class on a beautiful fall day. The sun was shining. The warmth bathed my face as Eric and I drifted toward the student union. We strolled through the Diag and stopped briefly to talk to a girl from Spanish class.
We crossed the street and entered a small courtyard. As I turned the corner I recognized a girl's silhouette out of the corner of my visual field. I looked up. She was 20 feet away. Her head lifted and our eyes met. As she smiled I couldn't help but smile back. We both paused as if our eyes were having a silent conversation.
She said. I'm sorry I didn't feel the same way about you....We were the best of friends though...I did love you in my own way!
And I answered. I know. But it wasn't good for me to continue the way we had.
I miss you.
I miss you too!
And then the moment was over. Eric and I entered the union and her image quickly jumped from reality to the recesses of my mind.
We would see each other again from time to time. We even talked once and went for coffee. But it was never the same. The connection was gone.
As the years pass the memories become more distant. And of all the thousands of joys and frustrations of a year of having my soul consumed and stomped on what remains is so little.
Those few seconds.
At the union. When our eyes met and we smiled at each other.
And the pain was gone.
We crossed the street and entered a small courtyard. As I turned the corner I recognized a girl's silhouette out of the corner of my visual field. I looked up. She was 20 feet away. Her head lifted and our eyes met. As she smiled I couldn't help but smile back. We both paused as if our eyes were having a silent conversation.
She said. I'm sorry I didn't feel the same way about you....We were the best of friends though...I did love you in my own way!
And I answered. I know. But it wasn't good for me to continue the way we had.
I miss you.
I miss you too!
And then the moment was over. Eric and I entered the union and her image quickly jumped from reality to the recesses of my mind.
We would see each other again from time to time. We even talked once and went for coffee. But it was never the same. The connection was gone.
As the years pass the memories become more distant. And of all the thousands of joys and frustrations of a year of having my soul consumed and stomped on what remains is so little.
Those few seconds.
At the union. When our eyes met and we smiled at each other.
And the pain was gone.
Friday, November 19, 2010
Snapshots From Childhood
We were feuding. As much as I, a 10 year old, and my eight year old neighbor could. The long hot summer days had taken their toll. My mother was busy at work and my dad had passed away. The nanny/housekeeper was tasked with keeping me busy. We strolled out on the front lawn with baseball gloves. I was Ryne Sanberg and Aurelli was Jody Davis (she thought he was so cute!).
Our game was shortly interrupted by Andy (my next door neighbor) and Tim who had just moved down the block. They were both a few years younger then me and had become fast friends. Currently they were united in their attempts to antagonize me.
They sauntered to the other end of Andy's front yard and started to throw a foot ball back and fourth. Aurelli glanced at me with a sense fof foreboding....ignore them...you know they are looking for trouble.
Andy and Tim quickly huddled for a moment and then made their way towards us. Hey...you want to join our football game. I looked up quizzically. My heart and mind paused and then started to wage a silent war. Aurelli shook her head...but it was to late. I put my arms out and Andy tossed me the football. Go long.
Tim ran off towards the other end of the lawn. I took a few steps back and launched the perfect spiral 20 yards down field. Tim put his arms up and the football hit its target square in the chest on the numbers. It bounced off and knocked him over stumbling to the ground.
Tim jumped up and looked at Andy. They both ran towards me. Andy was the first to reach me...Hey what do you think you are doing hitting him in the chest that way? Tim was close behind. Aurelli, who knew better then to leave us alone, stepped forward as Tim lunged toward me. She intercepted him but couldn't stop Andy from joining the fray.
As we rolled around on the ground Andy's father strode out the front door and grabbed his son under the arms and heaved up on his chest. I was free. Then he manhandled Andy and I and beckoned Tim. Come on...were going to your house to discuss this with your father.
My heart sunk and I was overcome with fear. Andy's father was a good man...I knew that. Tim's father was something different. Angry, belligerent, he never had kind words for me.
Moments later we were standing at Tim's house. Andy's Father knocked and a large sweaty man opened the door. He was over 6 feet, obese, his face a ruddy complexion and trickle of sweat omnipresent on his brow as if he had sprung a leak and was continously dripping out the contents of his brain.
He looked down at me and his eyes bulged. Oh no you don't...you're not bringin that kid inside my house...I hate that fuckin kid!
Andy's father took a step back as the door slammed. He was visibly shaken...shocked. He walked Andy and I back to his house and sat us down. Calmly he explained that we needed to stop fighting. That we were neighbors and friends. That life was to short to be angry at eachother. And that Tim's father was wrong and shouldn't have reacted that way.
Andy and I never fought again. In some strange way we felt bonded by such an odd experience. We were kids. It was simple. Tim's father's reaction was enough to make us think that we were to young to understand this adulthood thing. Better to be kids...play football...have fun...let the grown ups figure out the complicated stuff.
But I will never forget the vulgarity. The pure hatrid in those bulging eyes. It's probably been the only time in my life that I have experienced such venom directed solely at me.
Long after the memory of the houses, the faces, or the neighborhood fades away.... the hatred...the hatred is what I will remember.
Our game was shortly interrupted by Andy (my next door neighbor) and Tim who had just moved down the block. They were both a few years younger then me and had become fast friends. Currently they were united in their attempts to antagonize me.
They sauntered to the other end of Andy's front yard and started to throw a foot ball back and fourth. Aurelli glanced at me with a sense fof foreboding....ignore them...you know they are looking for trouble.
Andy and Tim quickly huddled for a moment and then made their way towards us. Hey...you want to join our football game. I looked up quizzically. My heart and mind paused and then started to wage a silent war. Aurelli shook her head...but it was to late. I put my arms out and Andy tossed me the football. Go long.
Tim ran off towards the other end of the lawn. I took a few steps back and launched the perfect spiral 20 yards down field. Tim put his arms up and the football hit its target square in the chest on the numbers. It bounced off and knocked him over stumbling to the ground.
Tim jumped up and looked at Andy. They both ran towards me. Andy was the first to reach me...Hey what do you think you are doing hitting him in the chest that way? Tim was close behind. Aurelli, who knew better then to leave us alone, stepped forward as Tim lunged toward me. She intercepted him but couldn't stop Andy from joining the fray.
As we rolled around on the ground Andy's father strode out the front door and grabbed his son under the arms and heaved up on his chest. I was free. Then he manhandled Andy and I and beckoned Tim. Come on...were going to your house to discuss this with your father.
My heart sunk and I was overcome with fear. Andy's father was a good man...I knew that. Tim's father was something different. Angry, belligerent, he never had kind words for me.
Moments later we were standing at Tim's house. Andy's Father knocked and a large sweaty man opened the door. He was over 6 feet, obese, his face a ruddy complexion and trickle of sweat omnipresent on his brow as if he had sprung a leak and was continously dripping out the contents of his brain.
He looked down at me and his eyes bulged. Oh no you don't...you're not bringin that kid inside my house...I hate that fuckin kid!
Andy's father took a step back as the door slammed. He was visibly shaken...shocked. He walked Andy and I back to his house and sat us down. Calmly he explained that we needed to stop fighting. That we were neighbors and friends. That life was to short to be angry at eachother. And that Tim's father was wrong and shouldn't have reacted that way.
Andy and I never fought again. In some strange way we felt bonded by such an odd experience. We were kids. It was simple. Tim's father's reaction was enough to make us think that we were to young to understand this adulthood thing. Better to be kids...play football...have fun...let the grown ups figure out the complicated stuff.
But I will never forget the vulgarity. The pure hatrid in those bulging eyes. It's probably been the only time in my life that I have experienced such venom directed solely at me.
Long after the memory of the houses, the faces, or the neighborhood fades away.... the hatred...the hatred is what I will remember.
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