In Memorium

I loved him as far as patients go. He was warm, and friendly, and needy. His thick accent always pleasant. Often he spoke in a mix of languages, intertwining one with another. Some I understood...some I didn't. His culture was different from mine. But very respectful. Physicians were held in high esteem.

The diagnosis was horrendous and of course the expected lifespan was short. Often he circled life's drain but usually found away to pull himself back. Long ago he had entered hospice but the truth of the matter was that I never completely accepted it. At least not emotionally.

He had been doing poorly for the last few days. I tried the few tricks that usually worked. Then I got the call this morning that he took his last breath and died..... just like that.

And as per usual I feel a great tinge of sadness and guilt. If I had done something different. Been more aggressive....been less aggressive. Could I have managed things better?

I picked up the phone to call his wife today. She said that she saw him last night. That his stroke induced garbled language cleared for a few minutes and he became very aware. He told her that he was dying and then preceded to give her a series of instructions. Then he said goodbye.

And so he died. And now I sit at my desk and try to discern what I learned from him.....

Maybe as physicians we give ourselves too much credit. That this strange dance of monitoring, measuring, and tweaking is all for naught. That maybe those who are going to live....we help recover faster. And those who are going to die...we help prepare for death.

And sadness, guilt, and blame are all just crutches we use to help maintain the illusion...

that we actually have one iota of control over our lives.

What Color Is Your Parachute?

I remember like it was yesterday. The first week of medical school. The guy with a PhD next to his name handed out a survey. It will take just a few minutes. Twenty or so questions. I attacked the scan tron like a familiar meal at my favorite greasy spoon. A....B.....B....A.

The banality of protocol. Age...race.....years of schooling. And then a simple question:

How comfortable are you with uncertainty?

I scoffed silently as I swayed in my desk. What does uncertainty mean to a medical student? Born into an idea and molded on a concept. Jordan what are you going to be when you grow up...a toddlers eyes hidden under his blankey....a doctor like daddy!

Uncertainty was a joke, wasted on the unsteady. Unschooled in prowess, abandoned by science and logic and abolished by basic college courses like genetics and physiology.

Uncertainty was for the weak! Not for the A++ student that us survivors had become. So we entered medical school and uncertainty was our challenge. Not a question mark but more like a beginning with a tenuous but stringent connection to an end. One just had to search.

And so it became our namesake....our attempt at becoming more...stronger...perfect. Reaching our goal and entering residency we could see the end in sight. The zenith where our efforts are always rewarded, and the sun always shines, and when things do go wrong it is because our attending is not up to snuff.

Until we leave the hubris of training. In the cold , cruel, real world of practice. Where instead of the enemy...uncertainty becomes the awkward bedfellow. Lurking around dark sterile corners, waiting to spring in our most insecure moments.

How comfortable are you with uncertainty?

Ha! How comfortable are you with death...and suffering...and self loathing...and fear?

I guess a helluva lot more then I would have ever expected.

If your not, for god sakes, don't become a doctor!

Attention Nurses-How To Be In The Top 50 Percent

My cell phone rang as I raced down the highway to the hospital.

"Hello Dr. G This is RN from the nursing home.....Mr. S is not looking good"

"What's wrong?"

"Heart rate is 250 and he is unresponsive"

"250? that doesn't sound right....how did you get that number?"

"That's what the pulse ox read!"

"Did you listen to his heart yourself to verify?"

"No"

"OK...whats the blood pressure, respiratory rate?"

"Hold on....let me ask the CNA"

"Never mind....I'm a minute away. check a stat cbc, cmp, get a set of vitals"

I walk in minutes later to find an alert, calm patient. Normal vitals signs and no distress. Apparently he was sleeping and the needle stick from the blood draw woke him up. An interrogation of his pacemaker/defibrillator would later show that he never had an elevated heart rate.

I get these calls all the time. Nurses calling with symptoms and vitals signs that make no sense. Riddled with incomplete information often on patients who they haven't laid eyes on. It drives me crazy.

The good news is that these scenarios do not occur with all nurses. In fact as far as the hospital and nursing homes go....about fifty percent of nurses are excellent. The other fifty percent...not so much.

In reality I don't know the trials and tribulations of being a nurse. It certainly is a complicated and difficult job. I don't want to pretend like I share their experiences. But I have been giving lectures on a weekly basis on nursing care. I believe there are just a few essentials skills that turn a mediocre nurse into a great nurse. Or at least the top fifty percent. Here's what I try to teach in my seminars:

Above all when calling a doctor to discuss a new clinical problem you must ...

Investigate

Please, please, please, please do not call me about a new problem without seeing the patient first. If there is a new rash...go look at it. A warm swollen leg...touch it. Don't take the CNA's word for it. If you call me I am going to ask you a lot of questions. You are going to be my eyes and ears. If you haven't investigated the problem yourself how can you see for me!

Anticipate

S0 the patient has a cough and crackles at the left base. What are the most recent vitals? When was the last chest xray? Is the patient on antibiotics already? Are there any drug allergies. If you call me and want a proper answer to your question come prepared. Have the chart, med list, and most recent labs in front of you. Because I will ask for this information anyway. You might as well have it ready.

Contemplate

Nurses are smart. I repeat most nurses are smart. They bring to the table clinical training, years of experience, common sense, and empathy. When you call me I want your opinion. Does the patient look sick? What do you think is going on?

I can't tell you how many times I have been stumped and turned to the nurse taking care of a patient and asked his/her opinion. Often that opinion helps me generate ideas or answers the question for me. I am secure enough in my abilities to ask for help. This is a team sport.

So that's it. Go from a mediocre nurse to at least the top 50 percent in three simple steps:

Investigate

Anticipate

Contemplate

And I will hold the greatest respect for you.

Migraine

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.

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.

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:

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

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.