I don't know when I lost my sentimentality.
Whaaap
With a thud the fish stops flopping up and down. It lays still on the floor of the boat. My camp counselor, a tanned college student, carefully places the paddle on the seat and cuts the fishing line. The hook remains dangling from the lifeless mouth.
He grabs the fish with his bare hand and throws it back into the water. He talks slightly above a whisper. I don't know if his words are directed at me or into the air.
Couldn't get the hook out of that one. He would have never survived!
*
My son and daughter sit on the curb in front of our house, stunned. The car pulls over as the dog's owner sprints around the corner. She stops a few paces away and screams.
The animal's chest heaves up and down slowly, but he is otherwise incapacitated. My daughter looks up at me quizzically?
Can we call an ambulance? Can we take him to the hospital?
I don't respond at first. The owner is now leaning over her beloved pet. She strokes his head and whispers softly into his ear. She is crying.
No honey. The dog is dying. There's nothing we can do
My son instinctively grabs my daughter's hand. They sit silently and watch as the dog's respirations slow.
I feel a strong urge to cover their eyes and walk them into the house. But I don't. I put my arms around my children and wait.
We all just wait.
*
So you're putting 421 on hospice?
The nurse leans over my shoulder as I write orders. It's been a long day and I don't feel like talking. I'm starting to drift.
Whaaaap
Sometimes I dream that all those fish are swimming after me. The hooks wag back and forth in their mouths as they pull IV poles behind them.
Her primary sent her here to get therapy. She's due for another round of chemo next week.
The nurse persists even though my mind is clearly elsewhere. She's starting to get on my nerves.
You know, most docs let the oncologist take care of this stuff.
Now I'm angry. I growl as I look up at her, but then think better of it. I turn my head back to the chart.
I mutter under my breath...
just loud enough to make sure she understands.
I wouldn't treat a dog that way!
Friday, October 14, 2011
Thursday, October 13, 2011
Departures and Arrivals
The woman sitting across from me is sniffling. Her chin is tucked into her neck, and a small tear barely leaves her eye before she wipes it away with a tissue. She balances her cell phone under her ear. She talks quietly. Her face contorts as she struggles to control her expression. As I watch, I listen to another flight begin to board.
We are in an airport. I can't help but wonder who this poor woman is talking to. I am a voyeur. I turn my head with embarrassment in the opposite direction, but against my will I glance back.
How often does human drama unravel in places like this? Is she breaking up with a boyfriend? Has she just been to a funeral? Did she say her last goodbye to a favorite aunt or uncle who is dying?
*
Sometimes my office also feels like an airport. There are many arrivals and departures. Each person comes on a different schedule. Occasionally many at once. Other times just a few stragglers.
And they bring their baggage. Usually I am more a helper and less a voyeur. I may procure a larger bag or help them rearrange their contents. Often a few things get discarded.
Before long they are running back to the gate to catch their plane. Waving goodbye until our next visit.
Where we will do the same thing all over again.
*
The woman is boarding her flight. By the time she leaves, the tears are gone. Maybe it was simply a bad day. She smiles as she hands her pass to the man at the counter.
And I remain in my chair, waiting. An elderly gentleman is talking on the phone a few seats away. I catch the last few sentences of his conversation.
Shingles....shingles you say.
We are in an airport. I can't help but wonder who this poor woman is talking to. I am a voyeur. I turn my head with embarrassment in the opposite direction, but against my will I glance back.
How often does human drama unravel in places like this? Is she breaking up with a boyfriend? Has she just been to a funeral? Did she say her last goodbye to a favorite aunt or uncle who is dying?
*
Sometimes my office also feels like an airport. There are many arrivals and departures. Each person comes on a different schedule. Occasionally many at once. Other times just a few stragglers.
And they bring their baggage. Usually I am more a helper and less a voyeur. I may procure a larger bag or help them rearrange their contents. Often a few things get discarded.
Before long they are running back to the gate to catch their plane. Waving goodbye until our next visit.
Where we will do the same thing all over again.
*
The woman is boarding her flight. By the time she leaves, the tears are gone. Maybe it was simply a bad day. She smiles as she hands her pass to the man at the counter.
And I remain in my chair, waiting. An elderly gentleman is talking on the phone a few seats away. I catch the last few sentences of his conversation.
Shingles....shingles you say.
Tuesday, October 11, 2011
My Keynote Address
My son's hand shoots skyward. The teacher appraises the group of students and then motions him to the front of the room. He smiles as he skips forward. All sense of trepidation is lacking. He is aware of the other students, the parents, and the teacher. But he seems unconcerned.
He gently lifts his bow to the strings. The piano starts with an introduction. And he plays. The bow screeches awkwardly at first. A few notes in, he catches his stride. His eyes close slightly.
Seconds later he is finished. He puts his violin in rest position and bows deeply. The crowd claps. He skips back to his seat with a smile on his face. He knows his performance is imperfect.
He doesn't care.
*
Tomorrow I will wake up early and leave my family. I will take a taxi to the airport where I will board a plane to Louisville, Kentucky.
I will attend the Amedysis Strategy Summit. On the second day I will step on stage in front of hundreds of people. My voice will be my bow. My knowledge, my instrument.
And I will play. With a little more trepidation than my son and likely a greater measure of imperfection.
But my joy,
my joy will be the same.
He gently lifts his bow to the strings. The piano starts with an introduction. And he plays. The bow screeches awkwardly at first. A few notes in, he catches his stride. His eyes close slightly.
Seconds later he is finished. He puts his violin in rest position and bows deeply. The crowd claps. He skips back to his seat with a smile on his face. He knows his performance is imperfect.
He doesn't care.
*
Tomorrow I will wake up early and leave my family. I will take a taxi to the airport where I will board a plane to Louisville, Kentucky.
I will attend the Amedysis Strategy Summit. On the second day I will step on stage in front of hundreds of people. My voice will be my bow. My knowledge, my instrument.
And I will play. With a little more trepidation than my son and likely a greater measure of imperfection.
But my joy,
my joy will be the same.
Monday, October 10, 2011
A Brave New World?
As I walked up the stairs I thought about the history of the building I was about to enter. Although the foundation was the same, almost everything else had changed. The hallways were updated. The patient rooms decked out with comfortable furniture and fancy televisions. I even marveled at the bathroom as I answered nature's calling. I could have been in a fancy hotel.
Yes. Things were different than when I started as medical director. Back then, no one doubted upon walking into the entrance that they were in a nursing home. The five senses exploded with unwanted stimuli. The moans and groans, the smell, and the faded, run down facade.
They were "the good old days". Hindered by appearances, we felt we had to provide excellence beyond compare. The patients were old, demented, and psychotic. But they were ours. The names rolled off our tongues with an ethnic flavor. We took care of our neighbors. Before the boundaries blurred. We were part of the community
There was something about being the red headed step child, the underdog. It created a strange sense of identity. We knew who we were.
*
With an infusion of money, the construction trucks trampled in. The act of breaking ground was an affirmation of survival. But it was also the beginning of a new era.
Staff changed. Our patients changed. No longer constrained by second hand clothes the facility attracted a new clientele. We didn't need the support of our community, we expanded against it.
I looked at my patient roster. So many names were holdouts from a time long passed. But there were also new names. New responsibilities.
It was time for me to say goodbye. I was no longer captain of this boat. My ship had sailed and I didn't belong. It was as if it was I, and not the building that was antiquated.
*
We are entering a new era of healthcare. Old ways are being replaced at a staggering pace. The cracked and crumbling facade of our institutions has given way to the technological marvels of modern day society.
But sometimes I feel like a lonely ship floating in the ocean. As I struggle against the seismic change of tides, I wonder whether I will drift along with the waves or be swallowed whole.
We have changed our outsides. We have slapped lipstick on the pig. But on the inside are we really any different?
Can we, as physicians, survive the new world that is being foist upon us?
Yes. Things were different than when I started as medical director. Back then, no one doubted upon walking into the entrance that they were in a nursing home. The five senses exploded with unwanted stimuli. The moans and groans, the smell, and the faded, run down facade.
They were "the good old days". Hindered by appearances, we felt we had to provide excellence beyond compare. The patients were old, demented, and psychotic. But they were ours. The names rolled off our tongues with an ethnic flavor. We took care of our neighbors. Before the boundaries blurred. We were part of the community
There was something about being the red headed step child, the underdog. It created a strange sense of identity. We knew who we were.
*
With an infusion of money, the construction trucks trampled in. The act of breaking ground was an affirmation of survival. But it was also the beginning of a new era.
Staff changed. Our patients changed. No longer constrained by second hand clothes the facility attracted a new clientele. We didn't need the support of our community, we expanded against it.
I looked at my patient roster. So many names were holdouts from a time long passed. But there were also new names. New responsibilities.
It was time for me to say goodbye. I was no longer captain of this boat. My ship had sailed and I didn't belong. It was as if it was I, and not the building that was antiquated.
*
We are entering a new era of healthcare. Old ways are being replaced at a staggering pace. The cracked and crumbling facade of our institutions has given way to the technological marvels of modern day society.
But sometimes I feel like a lonely ship floating in the ocean. As I struggle against the seismic change of tides, I wonder whether I will drift along with the waves or be swallowed whole.
We have changed our outsides. We have slapped lipstick on the pig. But on the inside are we really any different?
Can we, as physicians, survive the new world that is being foist upon us?
Sunday, October 9, 2011
Poor Role Models
He was cocky and arrogant. The kind of attending every medical student feared. I heard the rumors before his arrival. But I was hoping that reality was less harsh then word of mouth. I had only one week left in my Internal Medicine rotation. So far, I received glowing reviews from my residents and attendings. Seven more days and I would clinch the sacred "honors" grade that I needed to be eligible for the top residency programs. A "pass" would just about eliminate all the highly competitive options.
It was the beginning of my third year of medical school and I had chosen general medicine as my first rotation. I was already signed up for the early subinterniship like many of the other students who were entering the field.
As he walked into the resident's room for the first time, I waited cautiously. He scanned our faces briefly before flopping in a chair beside us. There was no formal introduction. No exchanging of names or titles. He nodded at the third year resident and spoke to no one particular.
So what do you got for me?
*
The rest of the week went similarly. He spoke only to the residents and barely looked in the direction of the students. His condescending demeanor dripped with sarcasm and contempt.
Occasionally he accompanied the team to the bedside. He rarely asked the patient questions or spoke to them directly. His statements were curse and robotic.
Unfortunately, he was brilliant. He was able to pick apart a patient presentation and pull out the relevant facts with ease. His skills were adroit. There was no doubt his presence was highly valued by the university. He spent ninety percent of his time in the lab. Likely some administrator relegated his minute clinical duties to the VA to minimize his ability to do harm.
*
On the last day of the rotation he walked into the lounge with a smirk on his face. He would return in the afternoon to watch each student perform a blind history and physical.
My resident scrambled to find an appropriate patient. He looked for someone who could tell a good story, and had a problem befitting a third year medical students fund of knowledge and abilities.
The attending returned later that day and we walked quietly to the patients room. To our surprise, when we entered, the room was empty. She had gone for a stress test.
Looking mildly annoyed, he asked the head nurse for another suitable patient to examine. She, of course, not realizing the purpose of the interview chose a complex medical patient with a rare disease. She thought it would be a good learning experience.
*
The interview was a disaster. The patient was demented and confused. His self described pneumonia was, in reality, a pulmonary embolism. He also had empty sella syndrome.
I absolutely flopped. And to add injury to insult, after I finished the attending performed a superb history and physical and elicited everything I missed.
He later sat me down and berated me for half an hour. He was disappointed in my abilities. That morning he had been ready to give me honors, but now...
*
My final grade for internal medicine was "pass".
Although I aced many other rotations as well as my subinternship, I would not be offered interviews at many of the top residency programs that I applied for.
Years later, as I look back on the experience, I realize that that hour changed my life.
I would never have been motivated to become the teacher that I am today
if I hadn't started with such a poor role model.
It was the beginning of my third year of medical school and I had chosen general medicine as my first rotation. I was already signed up for the early subinterniship like many of the other students who were entering the field.
As he walked into the resident's room for the first time, I waited cautiously. He scanned our faces briefly before flopping in a chair beside us. There was no formal introduction. No exchanging of names or titles. He nodded at the third year resident and spoke to no one particular.
So what do you got for me?
*
The rest of the week went similarly. He spoke only to the residents and barely looked in the direction of the students. His condescending demeanor dripped with sarcasm and contempt.
Occasionally he accompanied the team to the bedside. He rarely asked the patient questions or spoke to them directly. His statements were curse and robotic.
Unfortunately, he was brilliant. He was able to pick apart a patient presentation and pull out the relevant facts with ease. His skills were adroit. There was no doubt his presence was highly valued by the university. He spent ninety percent of his time in the lab. Likely some administrator relegated his minute clinical duties to the VA to minimize his ability to do harm.
*
On the last day of the rotation he walked into the lounge with a smirk on his face. He would return in the afternoon to watch each student perform a blind history and physical.
My resident scrambled to find an appropriate patient. He looked for someone who could tell a good story, and had a problem befitting a third year medical students fund of knowledge and abilities.
The attending returned later that day and we walked quietly to the patients room. To our surprise, when we entered, the room was empty. She had gone for a stress test.
Looking mildly annoyed, he asked the head nurse for another suitable patient to examine. She, of course, not realizing the purpose of the interview chose a complex medical patient with a rare disease. She thought it would be a good learning experience.
*
The interview was a disaster. The patient was demented and confused. His self described pneumonia was, in reality, a pulmonary embolism. He also had empty sella syndrome.
I absolutely flopped. And to add injury to insult, after I finished the attending performed a superb history and physical and elicited everything I missed.
He later sat me down and berated me for half an hour. He was disappointed in my abilities. That morning he had been ready to give me honors, but now...
*
My final grade for internal medicine was "pass".
Although I aced many other rotations as well as my subinternship, I would not be offered interviews at many of the top residency programs that I applied for.
Years later, as I look back on the experience, I realize that that hour changed my life.
I would never have been motivated to become the teacher that I am today
if I hadn't started with such a poor role model.
Friday, October 7, 2011
Mortally Wounded
I remember it.
As the call room door closed behind me, all semblance of light disappeared. I felt no guilt about missing rounds. I stumbled to the bed and sat down. Cradling my head in my hands, I waited for the gush of tears. They never came. Neither did the gut wrenching nausea or the searing pain in the chest. Nothing.
I felt absolutely nothing.
And that's when I knew I was lost.
*
I was overwhelmed within the first few minutes of internship. I clutched my stethoscope with sweaty hands as I followed the chief resident from ward to ward. He chattered incessantly listing a series of do's and dont's. I was barely listening.
The nurses bustled to and fro as I loitered by the chart rack. Eventually the chief returned with another resident in tow.
This is Jim. It's his last day of residency. He can't be hurt anymore!
My mind reeled. What did that mean..."can't be hurt anymore". Hurt by whom?
My question never made it to my lips. Jim quickly sputtered off a list of patients for me to follow. He handed me his pager and placed his arm around my shoulder.
Good Luck!
Sometimes, in the lonely moments over the next few years, I would wonder how Jim became invincible.
*
It's not like patients never died before. As a second year resident, I manned the ICU on my own. But this one was different.
Maybe I was a little to cavalier when I decided to intubate. Maybe not. But the damn tube wouldn't go down. And then Anaesthesia never showed up. We kept on paging and paging.
I finally got the tube in and within moments, he coded. We worked on him for thirty minutes.
When I called his wife, she seemed strangely distant. She came at 2am to sign the papers and make funeral arrangements. She didn't ask any questions.
With a heavy heart I worked through the rest of the night. There were too many sick patients to stop and mourn. To process. It was only later that it hit my like a ton of bricks.
*
The first daughter phoned from out of state. She explained that she didn't talk to her stepmother and was wondering how her father was doing. Moments later she was screaming at me. No...no...no.
The second daughter called from the road and would be arriving in a few hours. Her crying horrified me. It never stopped. After a few minutes the line went dead.
I told the last daughter in person.
She collapsed into my arms.
*
I would never hear from any of these women again. But they changed me.
Their grief left an indelible mark on my soul that would last long after residency.
By the time I handed my pager to a brand new intern I was mortally wounded. I was dead.
I guess I couldn't be hurt anymore either.
As the call room door closed behind me, all semblance of light disappeared. I felt no guilt about missing rounds. I stumbled to the bed and sat down. Cradling my head in my hands, I waited for the gush of tears. They never came. Neither did the gut wrenching nausea or the searing pain in the chest. Nothing.
I felt absolutely nothing.
And that's when I knew I was lost.
*
I was overwhelmed within the first few minutes of internship. I clutched my stethoscope with sweaty hands as I followed the chief resident from ward to ward. He chattered incessantly listing a series of do's and dont's. I was barely listening.
The nurses bustled to and fro as I loitered by the chart rack. Eventually the chief returned with another resident in tow.
This is Jim. It's his last day of residency. He can't be hurt anymore!
My mind reeled. What did that mean..."can't be hurt anymore". Hurt by whom?
My question never made it to my lips. Jim quickly sputtered off a list of patients for me to follow. He handed me his pager and placed his arm around my shoulder.
Good Luck!
Sometimes, in the lonely moments over the next few years, I would wonder how Jim became invincible.
*
It's not like patients never died before. As a second year resident, I manned the ICU on my own. But this one was different.
Maybe I was a little to cavalier when I decided to intubate. Maybe not. But the damn tube wouldn't go down. And then Anaesthesia never showed up. We kept on paging and paging.
I finally got the tube in and within moments, he coded. We worked on him for thirty minutes.
When I called his wife, she seemed strangely distant. She came at 2am to sign the papers and make funeral arrangements. She didn't ask any questions.
With a heavy heart I worked through the rest of the night. There were too many sick patients to stop and mourn. To process. It was only later that it hit my like a ton of bricks.
*
The first daughter phoned from out of state. She explained that she didn't talk to her stepmother and was wondering how her father was doing. Moments later she was screaming at me. No...no...no.
The second daughter called from the road and would be arriving in a few hours. Her crying horrified me. It never stopped. After a few minutes the line went dead.
I told the last daughter in person.
She collapsed into my arms.
*
I would never hear from any of these women again. But they changed me.
Their grief left an indelible mark on my soul that would last long after residency.
By the time I handed my pager to a brand new intern I was mortally wounded. I was dead.
I guess I couldn't be hurt anymore either.
Thursday, October 6, 2011
I Was Still The Apprentice
Dr. G was like the Jedi master of our residency program. He was board certified in multiple specialities. But it wasn't the training that set him apart. He was just brilliant. An educator at heart. No nonsense. He told you how it was and he was right most of the time.
The residents actively searched for cases to stump Dr. G. We connived to present to him at case conference, something he had never seen before. But mostly we sat back and enjoyed watching the mind of a master clinician at work.
He taught us lessons about being a physician. He hammered us on deductive reasoning. I can still here his raspy voice scolding me in the exam room when I'm struggling to put the pieces together:
Be the detective.
*
While Dr. G could expound on almost any topic, he was known as an expert in one disease in particular: Hereditary Hemorrhagic Telangectasia (HHT). An autosomal dominant disease, HHT was widely recognized among our residents. Patients came from far and wide to see Dr. G in his clinic. By the time I finished training, I treated at least ten patients with this rare problem.
Although years later my mind is fuzzy on the details, every time I see a person with chronic nose bleeds I think of HHT. Often when I hear hoof beats I think of this zebra.
*
I watched in the ER as my patient rolled back from xray. She was thirty five years old and plagued by anemia. She had been admitted to the hospital five times over the last decade for transfusions. She showed up at our door when fatigue and shortness of breath had become unbearable.
The laboratory values confirmed it. She lost quite a bit of blood. Given her good pressure and pulse rate it was likely that this occurred over several months. I introduced myself and started to question her.
As the details unfolded I became excited. Apparently she had nose bleeds since childhood. There was no other cause of blood loss. I examined her. When she opened her mouth I saw a few small red dots on her tongue. Telangectasias! The hallmark of HHT.
As I explained the diagnosis, I informed her that I knew one of the world's experts on this disease. We would transfuse her blood. Have her see an ENT to help with the nose bleeds. If she was willing to travel the few hours to St. Louis, she could even see Dr. G. himself.
*
As the phone rang I felt like I was in residency again. I was calling Dr. G to tell him about another patient. Could I stump him?
After exchanging pleasantries, I informed him that this was not a social call. I had a patient to discuss. I was about to begin with the details when he interrupted me.
What's the patients name?
I stammered. Epi...Mrs Epi Staxis
He laughed a deep belly laugh. I felt small. Like I was a student again.
Another HHT case!
I was taken by surprise.
How...how did you know?
He paused. Well I take care of at least ten different people from the Staxis family! Didn't she tell you she comes from St. Louis?
I felt a growing sense of embarrassment. Dr. G. made the diagnosis without even hearing a single detail of the patient presentation. He was still the Jedi Master. I was still the apprentice.
Didn't we teach you anything hear in St. Louis?
You gotta take a thorough Family History!
The residents actively searched for cases to stump Dr. G. We connived to present to him at case conference, something he had never seen before. But mostly we sat back and enjoyed watching the mind of a master clinician at work.
He taught us lessons about being a physician. He hammered us on deductive reasoning. I can still here his raspy voice scolding me in the exam room when I'm struggling to put the pieces together:
Be the detective.
*
While Dr. G could expound on almost any topic, he was known as an expert in one disease in particular: Hereditary Hemorrhagic Telangectasia (HHT). An autosomal dominant disease, HHT was widely recognized among our residents. Patients came from far and wide to see Dr. G in his clinic. By the time I finished training, I treated at least ten patients with this rare problem.
Although years later my mind is fuzzy on the details, every time I see a person with chronic nose bleeds I think of HHT. Often when I hear hoof beats I think of this zebra.
*
I watched in the ER as my patient rolled back from xray. She was thirty five years old and plagued by anemia. She had been admitted to the hospital five times over the last decade for transfusions. She showed up at our door when fatigue and shortness of breath had become unbearable.
The laboratory values confirmed it. She lost quite a bit of blood. Given her good pressure and pulse rate it was likely that this occurred over several months. I introduced myself and started to question her.
As the details unfolded I became excited. Apparently she had nose bleeds since childhood. There was no other cause of blood loss. I examined her. When she opened her mouth I saw a few small red dots on her tongue. Telangectasias! The hallmark of HHT.
As I explained the diagnosis, I informed her that I knew one of the world's experts on this disease. We would transfuse her blood. Have her see an ENT to help with the nose bleeds. If she was willing to travel the few hours to St. Louis, she could even see Dr. G. himself.
*
As the phone rang I felt like I was in residency again. I was calling Dr. G to tell him about another patient. Could I stump him?
After exchanging pleasantries, I informed him that this was not a social call. I had a patient to discuss. I was about to begin with the details when he interrupted me.
What's the patients name?
I stammered. Epi...Mrs Epi Staxis
He laughed a deep belly laugh. I felt small. Like I was a student again.
Another HHT case!
I was taken by surprise.
How...how did you know?
He paused. Well I take care of at least ten different people from the Staxis family! Didn't she tell you she comes from St. Louis?
I felt a growing sense of embarrassment. Dr. G. made the diagnosis without even hearing a single detail of the patient presentation. He was still the Jedi Master. I was still the apprentice.
Didn't we teach you anything hear in St. Louis?
You gotta take a thorough Family History!
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