Monday, April 25, 2016

Sometimes...

Sometimes before I go on a run, I take the laces of my jogging shoes and tie them together in a knot.  I wear the pair around my neck with each shoe falling to opposite sides.  The heels clunk against my chest as I make my last minute rounds.  It's as if running is my job and the shoes are the instrument I use to perform that job.  Eventually I slip them off my neck, and onto my soul.  It's time to go running.

Today started in much the usual fashion.  The first few blocks were rocky, but eventually I established a pace.  A mile in, I turned the corner, and I was on my beloved lakeside path.  I could still feel the thumping on my chest.  At first, I couldn't help but smile.  I was on the right path, the right journey.  I passed fellow runners, and we shared a knowing glance.  We were brothers and sisters, comrades in a common goal.

As the miles continued, my joy began to fade.  My feet burned and my knees started to buckle.  The sun battered my brow occasionally providing warmth, but often scalding.  I passed my normal turning point, but kept going.  The pain faded and was replaced by a certain fatigue, a weariness. I was still uncomfortable, but I no longer cared.

Suddenly, I tripped on the shoelaces as if they were still tied together, and collapsed onto the pavement.  For a moment a dagger lanced through my hands and wrists before abating.  The blood now dripped from my extremities.

But I was miles from the beginning, I couldn't just stop.

My pace home was slow and methodical.  The miles clicked by as my head hung down, no longer entranced by the joy of the lakeside path.  I hid my eyes from my fellow joggers as they whisked by.  I was embarrassed by my all to visible scars.  My all to apparent pain.  

I returned to the entrance of my house haggard and beat down.  I no longer remembered neither the joy nor the pain of the journey I had just taken.  Instead, I was empty.

Had I taken the wrong path?

I climbed up the steps and pushed the key into the lock.  I sat on the bench in the mud room and took off the blood spattered shoes.  For a moment I went to tie the laces in a knot again, and throw them around my neck.

Muscle memory.

Instead I chucked the miserable pair unattached into the hallway closet.

Maybe it is time to stop running.

Saturday, March 26, 2016

Arms Wide Open

We are born with arms wide open, and we die in much the same way.  It is that which we carry, in the time between, that defines us.

The new born, caught in the primordial stew of beginnings, is unable to recognize the difference between self and other.  She grasps and roots at inanimate objects with the same voracity she reaches for her mother.  It is a time of differentiation, a time of definitions

The toddler understands more of his surroundings  His eyes survey the landscape and fall lovingly on one gleaming object or another.  The word mine dribbles from his mouth as he learns the pleasure of lust.  The pleasure of ownership.  He lugs his baubles with him and looks longingly when his line of vision is distorted, object permanence has long been mastered.

The school age child shoulders a mountain of books.  A transition has occurred from ownership of inanimate objects to attainment of knowledge.  She transports with her a means to an end.  She holds in her precious hands the tools that will lead to an as yet ill defined version of success.

The young adult has completed the transition from objects, to knowledge, to affection.  He grasps tightly to his beloved, no longer satisfied with the baubles of the toddler or the knowledge of the school child.  He has traded in such worldly artifacts for something deeper, more complicated.

The new parent once more finds her arms encumbered.  Whether a crying baby, a car seat, or a dirty diaper, there is not much advantage in deeper contemplation.  Like the new born, she often finds herself grasping in all directions.  The lines of differentiation are again blurred.

Middle age can be a time of great consternation.  One's arms are often empty.  His children have grown and can carry some of their own load.  Instead he struggles with a metaphorical burden.  Will his children be successful?  Will his parents age well?  Will he make a difference in his profession, in the world?

The aged, once again, finds her hands full.  Whether it be a walker or cane.  She struggles with physical frailty and laments that others have to do the heavy lifting for her.  The time of building has long gone.

If we are lucky, by the time we die, we have used or let go of most our material possessions,  We have passed on knowledge to our loved ones.  And we leave this world empty, just as we entered it.

We are born with our arms wide open, and we die in much the same way.

Thursday, March 10, 2016

Letting Go

Vacation was perfect.  We went to one of those all inclusive places.  They slip a bracelet around you wrist and a world opens up.  The pool.  The beach.  Bars and restaurants.  I lounged by the pool and walked in the sand.  I ate far too much and actually slept late into the morning.  The staff was as kind and courteous as could be.  The kids were almost all smiles

Perfect

But as everything in life, even perfection has to end.  We packed up our bags, loaded onto the plane, and taxied back home.  That evening sitting in bed, I contemplated the little string bracelet that had been my passport  to such thrilling adventures.  My vacation was over but for some reason I couldn't bare to cut the cord.  I couldn't remove the bracelet.

Now the edges had become frayed and the color had worn from the string.  My skin didn't take too kindly to the material, and a small itchy rash had started to form.  My mind new that this bracelet was no longer my vacation.  It was no longer my happiness.  It was a small vestige of that which had once been.  A physical, tangible reminder of the ephemeral.

As the days grew long, and I threw myself head first into reintegrating into my busy life, I pined for the simplicity and satisfaction that that little piece of jewelry signified.  It was no longer the thing of my desire but a wisp, a memory.  It was my vacation on life support; gasping and sputtering and just barley alive.

And I clung to it during sleepless nights and overbearing days.  My wrist became fiery red and itchiness turned to pain.  Whenever things were going badly, I looked down hopefully at my wrist wishing to recreate a moment, a small taste of what was gone.

Eventually the pain got bad enough and I propped my arm belly up on the counter.  I grabbed a knife and  pressed the dull side to my wrist resting just below the band.  Then I pushed up quickly.

The string exhaled, splayed, and fell lifelessly onto the counter.  In an instant my vacation, a living/breathing thing, transitioned from a palpable finite object to a memory.

The rash cleared over the next few weeks, but I often caught myself looking down at my wrist.  Always half expecting to see the band still there.  For just a little longer.

Afraid of what it would mean to hold on.

Afraid of what it would mean to let go.

Tuesday, February 16, 2016

How Good Medicine Has Become The Exception

Joe had one of the best geriatricians in the city.  So when he got a call from the pharmacist saying his new prescription was ready, he assumed that it had to do with his recent annual visit and blood draw. His suspicions were confirmed, a few minutes later, when he got through to the nurse at the office.

Joe was politely informed that he had high cholesterol and was being put on a statin. Although he hung up the phone satisfied and raced out to the pharmacy to pick up his new pills, a casual observer might find a few things concerning.

Neither the doctor nor the nurse actually talked to Joe about the significance of high cholesterol. No one bothered to discuss with him the risks and benefits of statin medications.  There was no mention of side effects or complications.  No joint decision making.  And certainly no consideration of a trial of diet and exercise.

A few weeks later, Joe received his results in the mail.  He marveled at the total cholesterol reading of 227.  But no one explained that a large part of his total cholesterol was made up of HDL or good cholesterol.  Joe's HDL of 75 was actually protective when it comes to cardiac disease.  His bad, or LDL cholesterol, was 148.  Not perfect, but not horrible either.

Now, did I happen to mention that Joe is 85 years old and is only on one other medication?  He takes a piddling dose of Lisinopril for high blood pressure.  Joe has never had a heart attack.  Never had a stroke.  He doesn't smoke or have diabetes. He exercises daily and has a normal BMI and waist circumference.

Joe has an exceedingly low risk of having a cardiac event, and in his case, a statin has a much greater likelihood of causing harm than good.    

Yet now he takes Simvastatin, and avoids eating his favorite desserts.

This is not just a fictional story, it happened.

You would think that by now we would be better than this.

But a large number of physicians are still practicing medicine without using even a modicum of evidence or common sense.

And actively engaging patients in shared decision making is still the exception and not the rule.

Monday, January 25, 2016

Alarm Fatigue

I felt like the stack of charts rose past my head and all the way to the ceiling.  I pulled out my pen, opened the first, and started charting.  I took a moment before each note to collect my thoughts.  The patients were complex, the problems sometimes insurmountable.  The nursing station at the facility was buzzing with activity around me.  Phones were ringing, alarms were crying for attention.

On the desk beside me was a case filled with a dozen pagers.  Every thirty seconds, one of the pagers would sound off and vibrate.  The motion would send the case rattling against the desk and not only obliterate my concentration but also fray what was left of my poor fragile nerves.  Every thirty seconds a chorus: rattling, chirping, beeping, or chimes.

Every now and then a staff member would distractedly reach out, press a button on a particular pager, and then go back to whatever they were doing.  Hell, I even silenced the racket from time to time when the noise became unbearable.

I endured this dance for an hour as I finished writing my notes.  By the time I was done, my eyes were red and my hair was disheveled from running my hands through it.  As far as I could tell, the only function of this barrage was to drive the poor doctors, who often had no other choice but to use the desk for charting, crazy.  I had not seen one definitive action taken in response to the buzzing pagers, besides turning them off.

I passed the secretary on the way out of the nursing station and couldn't help but inquire.

Me: Hey, you know those pagers on the desk.  They are always going off.  What a racket!  What are they used for.

Secretary:  Those pagers?  They are connected to the patient's call lights.  Every time a person hits the button at the side of the bed for help, one of those goes off.

Me: Really?

Secretary: You know, like if a patient needs to get out of bed, or is hungry, or has to go to the bathroom.

Me: Or if they have chest pain, shortness of breath, or fell and broke a hip?

Secretary: Yah, I guess that stuff too.

Tuesday, January 5, 2016

Doctors, He Felt, Were No Longer Helping People

It was never his intention that the name would stick.  A decade ago, when he first began working in the restaurant, some of his fellow employees knew that he was formerly a practicing physician and started to call him "Doc".  Although many of his coworkers had since moved on, taking the knowledge of his previous profession with them, his moniker persisted.

Doc liked the simplicity and tedium of his bartending job.  He spent the majority of his nights doing what he liked most, interacting with fellow human beings.  He remembered a time when medicine offered such enticing rewards.  When he could sit across from a patient with a paper and pen and record only the most salient information.  He could look into their eyes, wax philosophical in the exam room, and still have enough time to comfort a grieving family member.

The practice of medicine was once both amazingly complex and laughably simple.  The convoluted path of the ailing body was matched by the enduringly straightforward need to be loved and cared for.  And Doc loved his patients.  He loved them so much, in fact, that the wave of computerization, legislation, and compliance almost got the best of him.

He no longer enjoyed his day to day activities.  His warm greetings and kind words were overtaken by a nagging electronic medical record system and voluminous rounds of paperwork.  Doc was deeply depressed and on the verge of suicide when he made the life altering decision.

He had no children, no wife, and no debt.  He would leave the job he once loved in order to save his own life.

And save his life, it did.

As the months past, Doc felt the stress wash over his body and fall like a puddle to the ground.  He started to laugh again.  He smiled at strangers as they shimmied up to the bar.  He became a spectacle on his own.  A group of regulars appeared at all times of the night to chat as he worked.

It took a full year before the phantom sensation of a pager buzzing on his belt loop finally disappeared.  Double that to get used to sleeping the whole night without being interrupted by a phone call.  Doc was happy, but couldn't forget quite everything about being a doctor.

Although his mind was elsewhere, his keen eye kept lurking back to his training.  He might notice a Bell's Palsy or the shuffling gate of Parkinson's in some unlucky patron making his way to a seat in the restaurant.  Occasionally he gave advice for minor ailments.  Originally his customer's eyes would raise in disbelief, but eventually they learned to trust his instincts.

Once a young man started to choke on a piece of steak.  When Doc heard what was going on, he leaped over the bar and ran to the table.  He performed the Heimlich, and cleared the man's airway.  It appeared as if his actions were too late.  But Doc expertly delivered a few breaths and started CPR.  The man recovered by the time the ambulance arrived.

It was times like these that Doc wondered if he made the right decision.  He still loved medicine deeply.  But he also knew that what doctors were practicing today was no longer medicine.  It was a bastardized version overtaken by technology, administrators, and rules that made little sense.

Doctors, he felt, were no longer helping people.

Monday, December 7, 2015

What I Believe The Public Should Know About Clinicians

The daughter of the patient walked out of the room livid.  She was convinced that the nurse had no business taking care of patients.  She seethed as she recounted all the supposed injuries and mistakes that had occurred.  I took a deep breath and paused for a moment, trying to collect my thoughts.

The daughter didn't know that I had watched this same nurse successfully perform CPR on a man the day before, and her quick thinking was one of the factors that save his life.  She had once recognized a rare side effect of a medication, and solved a clinical mystery that had hounded doctors, hospitals, and pharmacists for months.

In my mind, she was the best that clinical medicine had to offer.  Knowledgeable, kind, intuitive.

But this trend has been escalating over the last few years.  Patients and families wagging their fingers and nodding their heads angrily in the direction of clinicians.  Doctors, nurses, and therapists have been accused of being incompetent, lazy, or downright cruel.

There is a basic loss of faith in the ability of our healthcare practitioners.

I think that the Internet plays a role.  The ability to Google one's symptoms and come up with a host of diagnoses has made the populace feel that medicine is easy.  Furthermore, the lay press and some of our own physicians and administrators decry the system as befouled by errors.  They say that we account for as much death and disability as heart disease and cancer.

While I believe that medicine requires a continuous and stringent effort to improve itself, I also think that the populace is becoming progressively fooled and brain washed.

Here is what I think the public should know:

1)People die, for the most part, because they are sick.  Yes medical errors occur (even to healthy people).  But medical errors happen more often in deathly ill, hospitalized patients, with poor prognoses to start with.  The more ill the patient, the more complicated the care.  More medicines.  More tests.  More risky procedures.  More errors.  This doesn't mean that we must not strive to do better.  But all those articles about how "hospitals kill more patients than..." are ungenuine.
2)Complications are not errors.  A small percentage of people who get colonoscopies will have the unfortunate complication of perforation.  They may even die from it.  This is expected.  Same for post surgical deep venous thrombosis.  Same for deadly side effects of medications.  There is a cost/benefit ration.  We can do our best to mitigate risk, but we can't avoid poor outcomes altogether.  It's like a reverse lottery.  The grand majority do just fine, but occasionally there is a big loser.
3)A text book presentation of a disease is very rare in clinical medicine.  It happens infrequently.
4)Physicians are some of the most highly trained individuals in society.  Our education is arduous and can span more than a decade.
5)Medicine is one of the most researched fields known to man.  Billions are spent every year improving our clinical knowledge.  Our ability to treat cancer, heart disease, and injury is far better than it was even a decade ago.  Patient safety is, and has been, at the forefront of researchers minds for years.  We are making great improvements. Think anesthesia, hospital acquired infections, and surgical check lists.
6)physicians have active and time consuming requirements for continuing medical education and board certification. Greater, I believe, than almost any profession.
7)The legal system holds physicians to a high standard and the penalties can be life altering for the involved clinician.  The grand majority of physicians are sued at least once during their career.

In summary, medical practitioners are highly trained and skilled individuals who are plugged into an incredibly regulated and researched domain of human existence.

To treat them as if they are stupid or ignorant is unkind, to say the least.