Is Medicine Giving You PTSD?

I immediately noticed upon awakening that the intense jaw pain was gone.  I guess the TMJ was on hiatus.  Than I reached my hand down to my waist to make sure that the pager hadn't fallen off during sleep (as I do every morning); it wasn't there!  It took a few moments for me to remember that I had dispensed of it the day before.  For the first time in years, the buzzing, beeping, insistent mistress had been silenced.

And the rest of the week has been just like this.  No headaches, no jaw pain.  When I see a patient for a visit there is no ringing or buzzing interrupting my thoughts.  There are no overhead pages.  I can actually sit across from another human being and listen, you know, like regular people do.  Like someone has lifted a hundred pound weight from my back and all the sudden I can breath. I am light as a feather.

I feel like a first year medical student.  Free from the chains of overwhelming responsibility, I can return to thinking abut medicine for the pleasure of it.  No one pages a first year student out of the room for an emergency.  No one rushes him through an interview or scolds him for being too generous with his time.

All the things I hated about my job have suddenly disappeared.

How long can this last?  When will some malevolent force descend on me and take away this newly found joy that, until recently, I didn't even know existed?

Can I tell you how much I hated that pager?  That insidious soul sucker that buzzed against my skin in the middle of the night and woke me with heart racing: the bringer of bad news, evil things, death and disorder.  I started to jump even when the calls were for the most banal of issues.  I should have smashed it.  I should have snuck onto the train tracks and left it idling.

Yes, I know, it wasn't the pager.  It was the lifestyle that was giving me PTSD.  The lifestyle that was sucking every ounce of my soul and leaving me hollow, empty.

It is the lifestyle that most physicians still lead today.

The Home Visit

I guess it shouldn't have been a surprise.

Her house was exactly as I expected it to be.  The door couldn't have been more fitting; red wood with a green holiday wreath attached perfectly in the center.  The carpet was so white that I almost took off my shoes on the front porch before entering through the threshold.  The room was warm.  The ambient temperature was accentuated by a plethora of colors and fabrics in contrast to the stark carpet.

I stepped into her living room and unloaded my bag.  I took out my equipment carefully: computer, stethoscope, blood pressure cuff.  I glanced up at the book shelves as I prepared.  They were full of objects placed neatly in regular intervals.  Each was in it's correct place.  The place, I had no doubt, that it was inherently meant to occupy.

It was a new feeling of intimacy for me.  Not the kind one gets from doing a thorough exam, more like how you feel after you have been talking for a few hours at a coffee shop.  For possibly the first time in my professional career, I was on someone else's turf.  This was not my examining room.  There were no sterile walls or malfitting gowns.  Even my lab coat had been abandoned in the back seat of my car.

We stared at each other.  I cowered behind my computer as she relaxed in her reclining chair.  She looked more gaunt than usual.  Beneath the stylish clothes, manicured hands, and recently styled hair was a cachectic woman.  A woman who faced her cancer with the same cleanly order she decorated her shelves.

And I understood.

There would be no chemotherapy or surgery.  There would be no blood soaked gowns or protruding tubes.  These things were far to disorderly.  She would gladly trade in a few morsels of time to avoid such indignity.

She would die in her bed.  In her bedroom with her adroitly adorned picture frames and her fluffy pillows.  A little too soon for my taste as a doctor, but maybe that was OK.

I finished my exam and made some notations in the record.  I printed a few prescriptions to keep the pain and nausea at bay.   We shook hands before I left.

Crisp, clean, orderly.

It was like I was seeing her for the first time.   Seeing her as she really was.

And not some deformed image spit out by our healthcare's disfiguring house of mirrors.

Just A Small Town Girl

Just a small town girl.

Livin' in a lonely world.

It's funny how your mind can be in two places at once.  The boat is bouncing up and down off the coast of Puerto Vallarta.  The music blares from the speaker above my head.  My daughter is face down on a towel.  She writhes back and forth complaining about her stomach and the rocking motion of the ocean. 

I am a world away.  Sitting in my brother's room on a brown bean bag listening to the Journey album that he just purchased.  It's the eighties, and I probably am no more than ten years old.  We listen to the song over and over again as I commit the words to memory. 

She took the midnight train goin' anywhere.

It would be the first song that I memorized all the way through.  I daydreamed that I was on stage singing to a crowd of adoring fans (mostly girls).  Of course, my dreams never came true.  I never became famous.  Yet the song stuck with me through all those years.

Just a city boy.

My daughter looks up at me quizzically.  She no longer has the grimace of discomfort on her face.  Daddy, you used to sing this song to me!  Indeed, she is right.  When she was two years old she had so much trouble falling asleep.  So I would sing to her.  Horribly out of tune since I have no sense of tempo or melody.  And this was one of the few songs that I knew all the words to. This is the first time that she is hearing the original version instead off my warped, poorly executed warble.

All of the sudden, I feel such a strange sense of wholeness.  In a foreign land in the middle of the ocean.  My daydreams of singing this song to an adoring audience in a sense came true.  The lines of my life have twisted and turned but somehow tied these moments together over the decades.

And my dreams are nothing like what I had imagined when I was just a few years older than my daughter is now.  Yet I can't help but feel that everything happened exactly the way it was supposed to.  That indeed all those disparate and disconnected moments somehow have been woven into the pattern of my life.

Looking down into the soft sparkling eyes of my daughter, I feel great calm.  And I try so hard to hold on to the feeling,

because I know, in a moment or two, that it will dissipate. 

Almost Everything

Everything is beautiful in Puerto Vallarta. Almost everything.

The kids have left a half finished virgin strawberry daiquiri on the small lounge table next to us on the beach. I sit with a book lilting in my hands in the mid afternoon sun. The bugs come and go. A bee sniffs around the opening of the glass. He hovers ever so gently above the sugary brew unaware that he is about to falter. He lands nonchalantly on the froth but flutters his wings frantically when he realizes that he is stuck.

And I think that this death.

One moment you are parading your freedom in search of what ever drives a little bee's mind and the next you have cancer, are in a car wreck, or tangled in death's grip disguised as a froo froo girly drink sin alcohol.

My brother is a little less jaded than I. He reaches over, grabs a straw, and gently lifts the debilitated creature from the quicksand. He places it on the table. Although its wings are fluttering maniacally, the hind legs are weighed down by cherry red globs of liquid delight. He limps along forward unable to take off, unable to escape the horror that has befallen him. My brother, chiropractor turned surgeon, dips the straw in a glass of water and holds his thumb over the top. He sprinkles the sticky stuff off the bee's legs delicately with his make shift dropper careful not to inundate the poor creature.

Slowly but surely, his nursing pays off. The limping evolves into tentative walking. The bee crawls past me leaving a trail of red stuff on the table cloth that reminds me of blood. Eventually he makes his way back to the daiquiri cup, and I'll be damned if he doesn't start to climb back up. He inches past the base and heaves himself forward over the thickest portion in the middle. His strength is building, his confidence is growing.

And then he flies away.

But in my world, in my world he hoists himself up with his last bit of strength and falls over the ledge to certain peril. 

In my world, the temptation is just too great.

It's Time To Land This Bird

I have been doing a lot of travelling lately. Each trip begins in the planning phase. Usually there is a burst of energy. An idea flowers. Road blocks form and are hurdled over. This is the most critical moment. It only takes a light wind to blow us off course, to decide that the whole idea is a farce. How many jaunts have spanned the mind only to stumble when pen reaches for paper, when concrete overtakes the ephemeral.

But once the wheels have left the ground, once a comfortable cruising altitude is reached, a transition takes place. Now the journey has indeed started. The initial gusto gives way to a much calmer period. The view from ten thousand feet is grand and distant. Feet haven't hit the soil. Our mind creates and modifies a future that is not yet reality. Although there is no turning back, the eyes strain to see the shimmering land below.

There is a moment in every journey, however, as the plane breaks through the clouds. There is a jarring of turbulence and then suddenly the horizon appears. After all this time, details become clear. Below are cars and building, people and roads. It is our first view of what the destination really looks like. We had an inkling before, but is was a mere apparition of a hopeful mind.

I announced almost one year ago that I was leaving my current position to start a home based concierge medical practice. The original surge of inspiration gave way to a long period of planning. And indeed, I was cruising above the clouds for so long that I often wondered if I would ever land. I broke through the clouds today. I always thought I knew what the future looked like. Now I am watching the ground rapidly approach as I begin my descent.

I will go back to the beginning. Doctor and patient. One human being trying to connect with another.

The landing gear has engaged. The flight attendants are in position.

It's time to land this bird.

Cognitive Dissonance

I am in love with the old ways.

The wheels of my car struggle to grip the powdery snow of the unplowed highway. The sun's absence attests to the premature beginning of my Saturday morning. My wife and children are asleep quietly in their beds. Most of the world is in fact sleeping. Already, my dance card is full. Between two hospitals and three nursing homes, a number of crises are brewing. By the mornings end, I will sit by the bedside as one patient dies. I will have family meetings, make critical decisions, review labs and talk to specialists.

Unlike many of my colleagues, I still practice in the office, nursing home, and hospital. Even on the weekend. Whether on call or not. I will wake up in the middle of the night. I will go to sleep too late and rise far to early. My fatigue will be interrupted by flashes of wondrous energy. Day in and day out. I have found no other way.

I consider myself a modern man.

My wife and children form the nucleus of my daily activities. I try to be as involved as possible. Dinners at home, violin practice, nightly homework all interrupted by the nagging mistress hanging on my belt loop, the wanting mobile infidel.

I write, I blog, I tweet. I use the latest in EMR technology.

I don't know how to weather the changes that are coming quickly upon us. Once I bowed at the alter of diagnostic accuracy. Now, I realize that there are many parts to effective doctoring. Shared experience, understanding, and lasting bonds are often what I think most are in search of. These things take time. Time often given during nontraditional hours. Time when one should be with their family, sleeping, or even having fun.

I don't know how to choose the way forward. I don't know how to be a guide down roads that I have never travelled. For now I will continue to make my early morning trips, my tires trampling through the unplowed snow...

Making paths where none yet exist.

Silly Rules Made In Ivory Towers

Why must everything be so difficult?

Soni pushed her mother quickly into the building from the parking lot, she wore a strained look on her face.  The wheel chair appeared preposterously large for the aged figure cowering under the haggle of blankets.  They were enjoying the brisk air, taking a walk around the facility, when the elderly woman called out.  Her lips curled and she moaned deeply.

Now Soni's mother had stopped talking months ago, but the devoted daughter had become adept and interpreting the grunts and groans.  The sound her mother was presently making, however, was different, alarming.  Her one arm was dead, lifeless from the stroke, but her other hand clenched her abdomen.  She winced in pain.

Soni had a bad feeling.  Something horrible was happening.  She beckoned to a CNA who helped her mother into bed.  I walked in moments later, completing my rounds at the nursing home.  I bent over the bedside and examined my patient.  Her abdomen was rock hard.  Her brow was furrowed.  Her breath left her mouth guardedly and fluttered before escaping.  She was suffering.

I explained that indeed, something catastrophic had happened: a bad appendix, a perforated bowl, a ruptured aneurysm.  Soni nodded at me as she held her mother's hand.  There would be no hospital.  There would be no emergency room huddle.  Soni wanted her mom to die quietly in her nursing home bed.  The years post stroke had been difficult and fraught with misery and dementia.  Nature was asserting itself, taking back what had been forfeited prematurely.

And this was something that I was trained to do.  I ordered a sublingual form of morphine, called roxanol.   But of course the nurse and I both knew that it was not that simple.  The miracle drug meant to keep people like Soni's mom comfortable, can no longer be given just by doctor's order.  Even though the vial was sitting in the lock box at the nursing station, the dying woman writhing in pain had to wait.  First a prescription had to be written and signed by hand, faxed to the pharmacy, the pharmacist than had to release the medication and issue an authorization number.  It took ten minutes in all.  Ten wasted minutes while someone suffered.

When confused, agitated, and in pain, the poor woman started to clench her teeth.  I knew that my only choice was to go to an Intravenous formulation.  An IV was already in place.  But again a new prescription needed to be written, faxed, processed by the pharmacist, and a new authorization given.  This time, unfortunately, I delineated the number of milligrams instead of milliliters of solution.  The pharmacist made me rewrite the prescription and start the process all over again.  Another half an hour was lost.

Agonizing over the unnecessary pain my patient was suffering, I begged the pharmacist to hurry up.  He responded the way they always respond now a days...sorry, federal regulation!

Soni's mother died quietly in bed a few hours later.  Once the medicine was released, I was able to bring her the comfort she so desperately needed at the end of her life.   I wish I could have been even faster.

There is a troubling trend in the regulatory atmosphere of healthcare.  Nonsensical rules are binding the hands of caregivers.  We are facing ever steeper barriers to basic common sense care.  Regulations meant to protect the populace are becoming an agent of harm.

Unintended consequences of silly rules, made by naive administrators, living in ivory towers.