The first thing I become cognizant of is motion: the beating of the heart, the contraction of the muscles as I place the phone back onto the base or into my pocket, the shallow breaths that willow past the lips. Only then do I contemplate notifying the family and giving my condolences.
Death has followed me from childhood. Not as a specter lurking in the darkened corners but more like a willing companion in a yet undisclosed game of strategy. And as far as professions go, there is a false intimacy in doing what I do. To experience the aftertaste of mortality on such a regular basis without partaking in the bitter nectar, to place the little white cancer stick to ones lips and yet never inhale.
We are disconnected, I and those I tend to. It is never so apparent than in those seconds after the last breath is taken. There is a undeniable stillness in death. Anyone who has been present in the moment immediately can tell the difference. There is a transition from the living, breathing, and circulating to inanimate object. No matter how much we slow our bodies, blood still pumps, oxygen exchanges, and diaphragms pull down.
We look to the ephemeral, talk of such things as spirit and soul. I am at a loss in such conversations. Because as the warmth returns, I take a deep breath and make the phone call. I stumble through the words I have mumbled so many times.
I am so sorry for your loss. It was an honor and a privilege to take care of your loved one. If there is anything I can do to make this better..
But in reality my oft repeated words carry a certain hollowness. In an ocean of uncertainty they are merely tiny flecks of wood bobbing up and down in the great vastness.
They are utterances, vocalizations, vibrations that remind both speaker and listener that we are not yet standing upon the abyss.
They are motion.
Saturday, February 8, 2014
Sunday, February 2, 2014
I Did All This
Home visits are hard, there is no doubt about it.
I felt like I had been driving for hours. The thirty minute travel time showing on my GPS was woefully understated due to the arctic temperatures and colossal snowfall. My jacket and clothes felt caked with dried salt rubbed off from the car or somehow accumulated from the ether. I pulled the key out of the ignition and braced for the subzero temperatures. My bag, recovering on the passenger seat, was bulging with equipment: stethoscope, blood pressure cough, prescription pad. The edges of the satchel were frayed from being inebriated with excess. My first month into the new practice, I was unsure what I really needed to bring. Should I take the EKG machine every time? What about the printer?
I was lucky to have found the house in the first place. Tucked between a driveway and a bunching of overgrown trees, my GPS had to rejigger three times to deliver me to the wrong side of the culde-sac. The glory daydreams preceding the start of this practice receding, I hunkered down to the business of building a business.
Thankfully, the kindly face that opened the front door was a familiar one. I had come to the right place. I knocked the snow off my boots on the cement ledge before walking into the warm confines of the house. After a few pleasantries, I opened my bag of wonders, took out the computer, turned on the wifi hotspot on my phone, and produced a pile of documents that needed to be signed before any clinical visit could begin.
Thwarted.
My hotspot was malfunctioning. My MacBook couldn't pick up the network. Anxious to maintain composure to the innocent patient who had graciously signed on to continue under my care, I made small talk as I nervously refreshed the network button. Two, three, four times...no luck! I was going to have to do this one blind.
I stared blankly at the computer screen, and than turned my attention to the patient sitting in front of me. The encounter was more stressful than I had planned. Without access to my medical record, I had to piece together a med list and clinical information. Upon finishing my exam and doling out a few prescriptions, I apologized for my technical difficulties.
He assured me that it was no problem. Everyone had mobile issues in his area. It seemed that the thick air smothered the hubris of technology. My head hung low as I gathered my things to face the cold air and blowing snow. I felt the wind had been stolen from my sails.
As I reached out for my coat and shoes, my patient pulled me aside.
Here, come to the basement, I want you to see this.
He raced down the stairs forgetting that he had the knees of an octogenarian. I followed in slow motion trying to keep up with this suddenly invigorated senior. When I got to the bottom, it took a moment to adjust to the brightly lit studio. The basement was filled with beautiful landscapes, oil on canvas, water color, mixed media.
All the sudden, looking a few decades younger, the old man stared at me. His eyes were laughing, speaking without words.
I did all of this!
And indeed, I thought to myself silently,
so had I.
I felt like I had been driving for hours. The thirty minute travel time showing on my GPS was woefully understated due to the arctic temperatures and colossal snowfall. My jacket and clothes felt caked with dried salt rubbed off from the car or somehow accumulated from the ether. I pulled the key out of the ignition and braced for the subzero temperatures. My bag, recovering on the passenger seat, was bulging with equipment: stethoscope, blood pressure cough, prescription pad. The edges of the satchel were frayed from being inebriated with excess. My first month into the new practice, I was unsure what I really needed to bring. Should I take the EKG machine every time? What about the printer?
I was lucky to have found the house in the first place. Tucked between a driveway and a bunching of overgrown trees, my GPS had to rejigger three times to deliver me to the wrong side of the culde-sac. The glory daydreams preceding the start of this practice receding, I hunkered down to the business of building a business.
Thankfully, the kindly face that opened the front door was a familiar one. I had come to the right place. I knocked the snow off my boots on the cement ledge before walking into the warm confines of the house. After a few pleasantries, I opened my bag of wonders, took out the computer, turned on the wifi hotspot on my phone, and produced a pile of documents that needed to be signed before any clinical visit could begin.
Thwarted.
My hotspot was malfunctioning. My MacBook couldn't pick up the network. Anxious to maintain composure to the innocent patient who had graciously signed on to continue under my care, I made small talk as I nervously refreshed the network button. Two, three, four times...no luck! I was going to have to do this one blind.
I stared blankly at the computer screen, and than turned my attention to the patient sitting in front of me. The encounter was more stressful than I had planned. Without access to my medical record, I had to piece together a med list and clinical information. Upon finishing my exam and doling out a few prescriptions, I apologized for my technical difficulties.
He assured me that it was no problem. Everyone had mobile issues in his area. It seemed that the thick air smothered the hubris of technology. My head hung low as I gathered my things to face the cold air and blowing snow. I felt the wind had been stolen from my sails.
As I reached out for my coat and shoes, my patient pulled me aside.
Here, come to the basement, I want you to see this.
He raced down the stairs forgetting that he had the knees of an octogenarian. I followed in slow motion trying to keep up with this suddenly invigorated senior. When I got to the bottom, it took a moment to adjust to the brightly lit studio. The basement was filled with beautiful landscapes, oil on canvas, water color, mixed media.
All the sudden, looking a few decades younger, the old man stared at me. His eyes were laughing, speaking without words.
I did all of this!
And indeed, I thought to myself silently,
so had I.
Sunday, January 26, 2014
When Medical Care Hurts
When I was seventeen, I developed a medical problem due to no fault of my own. It was painful, it was embarrassing, and when it became uncomfortable enough to disrupt my life, I went to see a well known surgeon downtown.
The specialist, tucked away in the hallow halls of academia, stared down at me past a pair of spectacles perched at the end of his ever-protruding nose. When he examined the area, he spoke in a measured and controlled manner.
It's really kind of disgusting, actually.
These were not the words a self-conscious, suffering teenager wanted to hear.
He then proceeded to do an uncomfortable, totally unnecessary procedure, to "rule out other things" even though the diagnosis was obvious. He eventually offered a series of treatments. I returned to the office once a month, and low and behold the symptoms abated. I felt more comfortable. Maybe this nightmare was finally over.
When September came, and it was time to go to college, I still needed a few more treatments. I arranged to see a specialist at the university because I would not be able to travel back to Chicago. Although the new surgeon was no more affable, he showed up on time and asked few questions.
Unfortunately, the symptoms took a turn for the worse. I trekked back to the hospital, and sat impatiently in the specialists office. After waiting for over an hour, he entered the room, didn't bother to examine me, and said I would need surgery. The surgery would be minor, but recovery would take several months.
I immediately called the doctor from back home. After the two surgeons talked on the phone, it became clear that the second had never clearly identified the issue, and was treating blindly based on the previously established diagnosis. He offered surgery out of desperation without actually visualizing the problem.
Needless to say, I walked out of the office and never returned to either surgeon again. I did my best to treat my own symptoms, and six months later I was better. Nearly a quarter of a century later, the problem has never reoccurred.
I often think of these experiences when opening the door to an exam room to see a patient.
Many of the details of the offices, the personal characteristics of the physicians, or even the quantity and quality of the pain have disappeared.
What remains after all these years is not the suffering caused by the particular medical malady,
but the callousness of the two surgeons who treated me.
The specialist, tucked away in the hallow halls of academia, stared down at me past a pair of spectacles perched at the end of his ever-protruding nose. When he examined the area, he spoke in a measured and controlled manner.
It's really kind of disgusting, actually.
These were not the words a self-conscious, suffering teenager wanted to hear.
He then proceeded to do an uncomfortable, totally unnecessary procedure, to "rule out other things" even though the diagnosis was obvious. He eventually offered a series of treatments. I returned to the office once a month, and low and behold the symptoms abated. I felt more comfortable. Maybe this nightmare was finally over.
When September came, and it was time to go to college, I still needed a few more treatments. I arranged to see a specialist at the university because I would not be able to travel back to Chicago. Although the new surgeon was no more affable, he showed up on time and asked few questions.
Unfortunately, the symptoms took a turn for the worse. I trekked back to the hospital, and sat impatiently in the specialists office. After waiting for over an hour, he entered the room, didn't bother to examine me, and said I would need surgery. The surgery would be minor, but recovery would take several months.
I immediately called the doctor from back home. After the two surgeons talked on the phone, it became clear that the second had never clearly identified the issue, and was treating blindly based on the previously established diagnosis. He offered surgery out of desperation without actually visualizing the problem.
Needless to say, I walked out of the office and never returned to either surgeon again. I did my best to treat my own symptoms, and six months later I was better. Nearly a quarter of a century later, the problem has never reoccurred.
I often think of these experiences when opening the door to an exam room to see a patient.
Many of the details of the offices, the personal characteristics of the physicians, or even the quantity and quality of the pain have disappeared.
What remains after all these years is not the suffering caused by the particular medical malady,
but the callousness of the two surgeons who treated me.
Thursday, January 23, 2014
It's Time For Hospice and Palliative Care To Pivot
Movements come and movements go. To be memorable, to last, depends on continuously refining the message. The brand, by necessity blindingly clear in the beginning, must be anything but static. Ideas mature, knowledge grows, and movements pivot. They must pivot.
The meteoric rise of hospice and palliative care has had untoward affects. Specifically, the treatment of pain and suffering has dislodged itself from the moors of clinical medicine. A new generation of caregivers rightfully have focused on symptomatology, but have unwittingly separated the body from the soul. To deny that they are intertwined, is to practice a brand of medicine that lacks nuance.
When one treats edema from low albumin with diuretics, dehydration ensues, When one treats psychic pain with narcotics, patients become more sleepy but no less mired in pain. When one treats dementia induced agitation with benzodiazepines, more agitation is likely.
Good hospice care is grounded in classic internal medicine. If we are not asking why are patients feel what they feel, we will ultimately fail at palliating them. If we want to remain relevant. If we want this movement to have teeth, we must redefine our place in the medical stratosphere.
Here's how I see things.
Hospice and palliative care physicians should strive to be master diagnosticians. We must be the detectives that parse not only the physical but also the metaphysical. We can no longer define pain and suffering as diagnoses.
Until we understand the how and why, our solutions will be misplaced and cockeyed.
It's time to pivot.
The meteoric rise of hospice and palliative care has had untoward affects. Specifically, the treatment of pain and suffering has dislodged itself from the moors of clinical medicine. A new generation of caregivers rightfully have focused on symptomatology, but have unwittingly separated the body from the soul. To deny that they are intertwined, is to practice a brand of medicine that lacks nuance.
When one treats edema from low albumin with diuretics, dehydration ensues, When one treats psychic pain with narcotics, patients become more sleepy but no less mired in pain. When one treats dementia induced agitation with benzodiazepines, more agitation is likely.
Good hospice care is grounded in classic internal medicine. If we are not asking why are patients feel what they feel, we will ultimately fail at palliating them. If we want to remain relevant. If we want this movement to have teeth, we must redefine our place in the medical stratosphere.
Here's how I see things.
Hospice and palliative care physicians should strive to be master diagnosticians. We must be the detectives that parse not only the physical but also the metaphysical. We can no longer define pain and suffering as diagnoses.
Until we understand the how and why, our solutions will be misplaced and cockeyed.
It's time to pivot.
Sunday, January 19, 2014
It's The End Of The World As We Know It
Amongst the deluge of social media offerings of late, a small quack filled the airwaves for but a brief moment, a few weeks ago. While some say that the death of the medical blogosphere is greatly exaggerated, others lament the dearth of new and unique voices filling the vacuum. Indeed so many good writers have come and gone. Are we becoming extinct, or is this a short lived blip, a hiccup? Does anyone really care about creating content anymore, or are we just a lousy group of aggregators prone to navel gazing and self promotion?
And more importantly, does it matter? Anyone who has written publicly (for free) for long enough knows that we create content not for our readers, but for ourselves. We write to fill an insatiable need that burns in our bellies and burst into flames marking the computer screen with the irascible contents of our insides. Otherwise, it's just too hard, Putting pen to paper, day after day, week after week, can not be done for someone else. We are egoists, often aware of our audience in only the most oblique ways.
We come and we go. We write when the emotional energy is present and disappear when the drain of real life sucks us away from our own self reflection. Our voices become quiet and humble, but they do not disappear. And they return. Maybe once again on a blog, or in an op ed piece in a newspaper, or in a less verbose microblogging platform.
The question of the medical blogosphere, my friends, is quite irrelevant. The drum of human creativity yearns to be heard. Where and when, however, is much more an issue for the audience. If you want to continue to hear the daily smattering of self involved creativity,
you might just have to intuit which way to roll the dial.
Sunday, January 12, 2014
All Pain Eventually Stops
You look at me incredulously.
And indeed, what I've just said has probably shocked you. That was not my purpose. You see your loved one in the ICU, medical floor, or nursing home. There may be tubes or IVs affixed in their proper places. You see suffering.
Your loved one is dying and you are crippled by your own incapacity, my incapacity. But look closely. There is no sweat on the brow. The heart rate is measured and steady. In fact the room is calm. This death will be quiet and subdued.
It is your suffering that I worry about.
I repeat myself, and watch your eyes closely for reaction. I have done all I can for your relative. They are likely past the pain, or will be soon. But you, you my friend will question yourself. You will dissect each moment, ruminate on each decision. Your suffering has just begun.
I wish to protect you.
You did everything right. Your love was more powerful than my medicine. Your presence was more enduring than my treatments. And your ability to understand this, your ability to let go of the guilt and be present will heal more than any morphine drip tethered to an unwilling forearm.
There are certain truths you learn in this business.
All pain eventually stops. And suffering is generally left for the living.
And indeed, what I've just said has probably shocked you. That was not my purpose. You see your loved one in the ICU, medical floor, or nursing home. There may be tubes or IVs affixed in their proper places. You see suffering.
Your loved one is dying and you are crippled by your own incapacity, my incapacity. But look closely. There is no sweat on the brow. The heart rate is measured and steady. In fact the room is calm. This death will be quiet and subdued.
It is your suffering that I worry about.
I repeat myself, and watch your eyes closely for reaction. I have done all I can for your relative. They are likely past the pain, or will be soon. But you, you my friend will question yourself. You will dissect each moment, ruminate on each decision. Your suffering has just begun.
I wish to protect you.
You did everything right. Your love was more powerful than my medicine. Your presence was more enduring than my treatments. And your ability to understand this, your ability to let go of the guilt and be present will heal more than any morphine drip tethered to an unwilling forearm.
There are certain truths you learn in this business.
All pain eventually stops. And suffering is generally left for the living.
Tuesday, January 7, 2014
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.
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.
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