Wednesday, February 29, 2012
I never liked the idea of floaties. Much better, I thought, to let them struggle and build on the lessons from last summer. But as the days went on, we realized that they would have more fun with a little independence.
The kids were overjoyed when we fit the balloon like apparatus over their arms. They were released from their own physical restraints.
All impetus to grow and learn was gone.
The oversized spinal needle gleemed as I held it up before attaching the 50 cc syringe. I had worked my way through the pulseless electrical activity algorithm and finally came to pericardial tamponade.
The hustle and bustle of the VA was oddly quiet at midnight. A litttle over a year ago I was a medical student, now I was the most senior physician in house. I was about to plunge a large needle below the xiphoid process and angle up toward the heart. Then I would pull back and advance slowly.
The blood squirted into the syringe like an avalanche of red water. I looked up at the moniter and noticed that the rhythm converted to sinus. Moments later, I palpated a pulse when groping for the carotid artery.
My patient would code a few more times that night before eventually succumbing. Each time, the interns and I would race to the bedside and commence resuscitative efforts. There were no attendings, no seniors residents, and no floaties.
A decade later, medical training has changed. The transition from learner to decision maker is more gradual. By the third year of training, many residents have never run a code by themselves.
The problem with flotation devices is that they allow you to survive when you are a weak swimmer. They do not help you develop the skills you will need to keep your head above water. They are a crutch. Life saving in the beginning, deadly in the long run.
We need to clarify this duality in medical education. Careful oversight has to be balanced with incremental decision making and independence.
At some point or another, the floaties have to come off.
Are the doctor's of tomarrow going to know how to swim?
Posted by Jordan Grumet at 8:43 AM
Tuesday, February 28, 2012
We are creatures of habit. Drastically changing the settings does nothing to alter the internal milieu. But time has a way of becoming less fluid. The wrist watch is discraded and the awareness of date and day dissapear.
There is no beeper buzzing and vibrating on my belt loop. Fifteen minute appointments are replaced by meandering afternoons on lazy beach chairs. Nobody is looking for me.
Nobody is calling my name
Posted by Jordan Grumet at 9:15 AM
Sunday, February 26, 2012
And for a moment I became a farmer. I worried of fields of corn, pasteurs of cattle. I was a small business owner with mouths to feed and employees depending on me. Could I really afford to take vacation and leave the daily responsibilities to someone else?
Then today, while sitting by the pool talking to a stranger, I became an investment advisor. I managed millions of dollars made by others. They laid their wealth at my doorstep like the paper boy delivers his daily news.
Each decision became the difference between mounds of money or piles of dust. They approached me with complete trust, as if trust was not a fickle servant. Could I afford to be offline for so long?
This evening, sitting in an Italian restaurant, I was the piano man. My hands were the anvils that molded my prosperity. I bounced from gig to gig, often not knowing when may next windfall would appear.
Would the waves crush my fingers rendering them useless? Would the smokey bars and fine dining establishments shun me If I wasn't available to answer their calls?
Tonight, I will dream that my absence will go unnoticed. That I will not have missed any emergent hospitalizations, unexpected deaths, or new diagnosis of cancer.
I will hope that my desperate need to take vacation and leave for a week,
will have no impact whatsoever.
Posted by Jordan Grumet at 6:04 PM
Friday, February 24, 2012
I'll Stand Outside
This Woman's Work
This Woman's Worth
Ooh, It's Hard On A Man
The two young boys bounced a rubber ball back and forth as Alex sat in the chair. His legs pumped up and down, and he repositioned himself nervously every few seconds. His eyes cast down as if he could stare intently enough to lighten his burden.
His wife was also under my care. At the moment, she was enduring her weekly dose of poison directed at a few unwieldy breast cells, but wreaking bystander havoc on her whole body.
She was in the mist of the roughest patch. The oncologist had told them that her chances were even at best. Alex, filled with anxiety, bore the weight of the family. The kids still needed to eat, go to school, and show up on time for soccer practice.
Alex tried to keep a semblance of calm in a world that was falling apart around him.
I Should Be Crying But I Just Can't Let It Show,
I Should Hoping But I Can't Stop Thinking
How would he survive without her? How would he carry on the monumental task of bringing up two small children alone?
Sitting in the exam room for his appointment, neither of us felt like talking. I waited for Alex to show some sign that he was ready. I pushed over a box of Kleenex and he cleared his throat. Nothing came out.
No matter what happened, their lives were forever changed. Even if she survived the initial battle, the hidden threat would remain coursing through her body like a feral animal. It waited to pounce when her defenses were low, and snuff out all signs of misplaced hope.
All The Things We Should've Said That I Never Said,
All The Things We Should Have Done That We Never Did,
All The Things We Should've Given But I Didn't
Alex didn't know then, what we both know now. That years later his wife would be alive and healthy. I see Alex once a year for a physical. It only takes moments to realize that something irretrievable has been lost. His undying optimism has been replaced by stoic acceptance.
He has his wife, but his innocence is gone. His sleep will never be as peaceful.
Oh Darling Make It Go,
Make It Go Away...
*Lyrics taken from This Woman's Work, versions sung by Maxwell and Kate Bush
Posted by Jordan Grumet at 6:37 AM
Thursday, February 23, 2012
As physicians we exert such glacial efforts to preserve life. We struggle with frailty against the whims and taciturn nature of father time. We suffer with our patients and stare down the barrel of our own inabilities with each death certificate we sign.
How many times have we watched the daughter mourn the loss of her father? We sit quietly as the husband sheds tears at the bed of his fallen wife. We face each new diagnosis: cancer and heart failure, diabetes and coronary artery disease.
We struggle with the residue of the day as we drive home to our families and envision each horrible diagnosis in the smiling faces of our precious spouses and children.
There are many sleepless nights. There are days where the bile engorges our bellies and leaves a bitter taste at the tip of our tongues. Yet we persist. We remain come hell or high water.
We can only gently alter the march of the aged; patients come and go, battles are lost.
Our distaste for destiny is salted with the tears of acceptance. The human body contracts disease. People are born to die.
Yet when I read the news today, I felt nothing but utter despair. A nine year old Alabama girl died after being ordered by her step mother to run around the house for hours till exhaustion. She was being punished for stealing a candy bar and lying about it.
As the article mentioned her low sodium and seizures, I found myself tumbling back to my medical reality. The exam rooms were filling with early appointments.
I will enter each room this morning with a heavy heart, and battle for the lives of the elderly and those unlucky enough to have picked the short straw.
Yet I can do nothing to ease the pain of that tragic nine year old. She died alone and steeped in shame.
I wish I could have fought for her.
Posted by Jordan Grumet at 2:12 PM
Wednesday, February 22, 2012
Cruising down an empty expressway on a quiet Chicago night tends to make the mind wander. Each year I find myself making this solitary trip a handful of times. And without a doubt, I never regret the decision to sacrifice my spare time to do what's right.
As I pulled into the hospital parking lot, I couldn't help thinking about Mrs. Smiley.
I met Mrs. Smiley years ago on a night much like this. She was new to our practice and had scheduled an appointment for the very next day. But the night before she developed a severe cough and came to the emergency room. She had been on large doses of immunosuppresants to control her rheumatoid arthritis and was told to be aware of the first signs of infection.
Her chest xray showed a dense pneumonia and she was transferred to the medical floor for admission. The nurses call me an hour later and awoke me from a deep sleep. Mrs. Smiley's blood pressure was low and her respiratory rate was increasing. I gave a few orders and climbed out of bed taking care not to wake my wife.
An hour later I was standing by Mrs. Smiley's bed and talking with her husband. The blood pressure responded to a fluid bolus. Her lungs cleared with a nebulizer. As I left the room I could see the relief flash across their eyes.
She would be discharged in a few days with antibiotics and a follow up appointment in the office.
Years later I still see Mrs. Smiley in the office from time to time. Although she has had her up and downs, she always seems to bounce back. Our relationship is built on trust and mutual admiration.
She is quick to reminisce about the day we met and how I "rushed" into the hospital in the middle of the night to see her. She gently chides and calls me "her night in shining honor".
We communicate easily and move from laughter to serious medical discussions without pause. If you listen closely you'll here the hidden conversation masked beneath details and pleasantries.
Mrs. Smiley says, "I have faith in you."
And I reply, "If you need me,"
"I'll be there!"
Posted by Jordan Grumet at 4:58 AM
Monday, February 20, 2012
It wasn't her fault. She was only following directions. But the licensing committee wanted clarification of a few issues filled out on the previous form and "discovered" in the medical record. For instance, when I used the diagnosis of "dizziness and giddiness" back in 2005, what had I meant. The sweat poured down my brow as I hunched over the EMR and traced back to the visit. As I suspected, she had momentary dizziness in association with an upper respiratory infection.
And there was a reference to her physical in 2010. Had I worked up the cervical lymphadenopathy? Again my irritation was growing as I found the note. Self limited, due to a mild case of Strep. It had resolved long ago.
I fiddled with the EMR in an attempt to compose a letter that would be printed and mailed to the appropriate agency. I glanced up at the clock. I was running fifteen minutes late.
I wanted so badly not to be angry.
But as I typed out the useless document, all I could think about was the countless hours spent on such idiotic tasks. How many "face to face" encounter forms had I filled out in the last week? How many preauthoriztions were due on patients who hadn't even changed meds?
As the years pass, my administrative and clerical responsibilities are growing. More energy is spent in the exam room checking boxes and filling out forms. Less time is allotted for the evaluation and treatment of acute and chronic illness.
In a way, I've been spoiled. As a physician, I was taught that I was too important to waste time on such menial tasks. I handed the paper to someone else, and moved on to clinical work. That is what I was trained to do.
Today, however, there is no longer any one to do the paperwork for us. Physicians are adapting by learning shortcuts. Instead of toiling longer hours, they are working "smarter". Which means time spent on clerical tasks is stolen away from patient care.
Are you wondering where your doctor is?
He's probably locked up in a small room with a pile of papers wending it's way to the ceiling.
He is doing exactly what he was ordered to do:
provide "health care".
Posted by Jordan Grumet at 9:44 AM
Saturday, February 18, 2012
After tripping clumsily back down, she sprinted to the table and crawled into her private sanctuary sealed from the world by the tablecloth. She rolled the metal cog with her thumb and watched the spark evolve into a mesmerizing glow of blue then yellow light.
Her baby brother started to stir and she craned her neck to listen for the cries she expected to come from his bedroom. As she turned her attention back to the gleaming object, she gasped in horror. The flames had jumped out of her hand and spread to the white cloth hanging down from the table. She sat transfixed for a moment until the woody smell wafted into her nostrils.
Quickly, she backed out and ran towards her brother's room. She pushed a stool to his crib and climbed up. It took all her strength to bend over the railing and scoop up the crying infant.
By the time she exited his room and ran towards the door, she found her passage blocked by malevolent wisps and fiery tendrils. She turned abruptly and scurried into her mother's room. She swiped the rosary beads off the dresser and crawled into the closet with her screaming brother snuggled tightly under her chest.
The last thing she recollects is arms of smoke rising from the crack in the door and forming a choke hold around her neck. She's not sure when her brother stopped screaming or when the fireman broke down the door.
She doesn't remember the funeral a few days later.
Angela was tolerating the back pain. She had done the MRI and could put a name on the lances of fire that shot down her thighs and into her calfs. But the shortness of breath was becoming debilitating. Her daily trek on the elliptical was exhausting and sleeping flat in bed was nearly impossible. The sensation came out of the blue and gripped her from inside out.
Her blood tests, chest xray, and electrocardiogram were normal. I probed into her life and could find no signs of anxiety or depression. I was on the cusp of considering a more aggressive work up when her symptoms disappeared. We decided to watch and wait carefully. We planned for a follow up the next week.
A day later her name popped back up on my schedule. As I walked into the room, I explained that it was either time for cardiac testing or that this could all be anxiety and depression. I suspected panic attacks.
When the words left my mouth, Angela shook her head in agreement. When she woke up the night before gasping and holding her throat, she had an epiphany. Her symptoms started shortly after getting the MRI a few weeks ago.
The enclosure in the metal tube must have brought back deeply buried memories of being trapped in the closet the day her brother suffocated. With this realization, her lost childhood returned. She could now recall the funeral and her brother's angelic face. How many times throughout childhood had she awoken form a deep sleep with her heart racing and gasping for air?
She was sobbing now.
I have never faced these issues.
There is much monotony to being a physician. I have seen more variations of the common cold than I ever thought possible during medical school. But the foibles of the human body are often surprising.
You never know what you are going to face when you open that exam room door. Sometimes it's chest pain. Others it's a runny nose.
And occasionally it's a middle aged woman trapped in the closet with a dead baby in one hand and rosary beads in the other. Decades later she is still mourning,
and begging for self forgiveness.
Posted by Jordan Grumet at 5:06 AM
Friday, February 17, 2012
Primary Care Goes Back To School!
The article described how internists and family practitioners are falling short of meeting current guidelines for the treatment of common cardiovascular ailments.
Another recent study noted that the number of specialty referrals per patient has skyrocketed over the last decade. Of course, you know who is being blamed for that one.
We are facing an identity crisis in Internal Medicine. The older generation labors under intense pressure to maintain salaries and finish paperwork. They struggle to complete their daily tasks in a ten hour day. The younger generation is all about lifestyle. They are accepting bloated salaries from desperate health systems to work a nine to fiver without call or hospital responsibilities.
And in the midst of the chaos, an ancient relic is being lost. The Internist, pejoratively known as the flea, would grab hold of his patient and never let go. They were scholarly, brooding, scientists who were challenged with the most difficult cases. There was intellectualism and pride.
The "hand off" is becoming the hand over. As we release ownership of our patients and leave the deep thinking to the specialists, we not only abandon rational patient care, we erase the need for our own existence.
Countless non physician practitioners are chomping at the bit of clinical care. They both climb the professional ladder as well as wait for our skills to degenerate. And to the joy of health care reformers, they ask for a lot less payment in return.
Today I call for elevation. Are we going to use the craft we fought so hard to obtain or are we going to wait for extinction.
Long ago, giants roamed the earth. The question for today's internist:
Will we be mice or men?
Posted by Jordan Grumet at 6:14 AM
Wednesday, February 15, 2012
The raspy air moved in and out of her lungs in fits and starts. She had been in the hospital for a few weeks. Her pneumonia was the final push that caused the boulder of chronic lung and heart disease to spiral towards the bottom of the hill.
This was her third stay in the ICU. Her husband and I discussed that she may not survive this hospitalization. He stoically excepted my pronouncements and yet remained gentle and upbeat.
When I turned to leave the room, I could hear him crouch over the embattled body of his wife. His whisper was barely audible.
Happy Valentine's day, love.
The demented woman in the wheel chair made herself at home at the nursing station. She watched the comings and goings of the extended care facility and was sure to add commentary to anyone who happened to pass by. She was particularly smitten with a young male CNA. Her inappropriate behavior was a byproduct of her loss of executive functioning. She eyed him as he turned the corner.
Hey good looking, you want to be my Valentine.
She licked her lips and the CNA quickly jumped away from her grabbing hands. I sunk down in my chair hoping she wouldn't see me. I watched as her head jerked in my direction. Her white strands of hair frazzled and her face hidden behind thick black glasses that were missing the lenses.
Doctor, doctor, my boobs hurt! You want to examine them?
My face became warm and my cheeks flushed. At first I tried to ignore her but the pleas became more fervent. Her breast exam the week before (prompted by the same complaint) had been normal.
OK, I'll get Nurse Radcliffe to accompany you back to your room and get things ready.
When she realized we would have company for the exam, she sighed deeply and spoke as she turned her wheel chair.
All the sudden I'm feeling better.
My son and daughter laugh as they run towards the car. Their faces are smeared with the remnants of a feast devoured in their classrooms earlier in the day. Bits of cookie dot my sons upper lip like a mustache. My daughter has chocolate colored smudge on both cheeks.
They carry folded pieces of paper with primitive lines of crayon dotting the front cover. They offer them up to me as I struggle out of the car carrying my computer and other byproducts of a day spent in the office.
Their faces beam with the innocence and joy of experiencing all of lifes wonders for the first time. They yell out in unison.
Happy Valentine's Day Daddy!
Posted by Jordan Grumet at 5:15 AM
Tuesday, February 14, 2012
As I grew older, I eventually formulated an answer. When my father died, I was seven years old and he was my idol. I copied his movements, his words, and then I copied his profession. My father was a highly respected oncologist and often treated the sickest patients. He received many accolades as well as the love and respect of his colleagues.
I always wondered, if he had lived longer, would I have grown less enamored? What would have happened when I reached the age where boys question their fathers and become disillusioned? Would I have changed my mind and wanted to be a sports star or a policeman? I’ll never know.
The idea of becoming a doctor stuck with me. It carried me through successes and failures. It created a confidence that never questioned if, it only questioned when. It built a story of my life that made sense. My father’s tragic death strengthened my calling to become a physician. I would carry on the tradition and touch countless lives. From death would come rebirth. By helping others, I would turn my sorrow into beauty.
When I started residency in July of 1999, I felt confident that I was doing my life’s work. I came to the hospital early the first morning. The chief physician brought me to the third-year resident who was covering the patients who would become mine. This was the resident’s last day of training. I will never forget the phrase my chief used when introducing him.
He said, “This is John. You’re taking his patients. Today is his last day of residency. He can’t be hurt anymore!”
My thoughts raced. What did he mean “can’t be hurt”? Who was hurting him? And why couldn’t he be hurt anymore? Unfortunately, I would eventually learn.
In my second year of training, I was given more independence then before. I worked in the intensive care unit without direct supervision. During the day the ICU attending and fellows were available, but at night I was on my own.
One evening, early in my first month, I faced a situation that changed my life. One of the patients had severe respiratory problems and needed to be placed on a ventilator. He was elderly and I wasn’t sure what was wrong.
Before I began the procedure, I paged the anesthesia attending on call as a precaution. Within moments of getting started, things went terribly wrong. I couldn’t get the endotracheal tube in correctly! I kept trying, but it was useless. And, although we called over and over again, the anesthesiologist never showed up
My anxiety rose as I placed a mask on the patient’s face and delivered life saving breaths. I could feel the confidence leaving. I struggled for what seemed like hours before another resident, walking by the ICU, came in and helped. After flailing for another fifteen minutes, we finally got the patient intubated.
Within seconds the patient’s blood pressure dropped. We started CPR and injected epinephrine without benefit. The heart monitor went flat and he died.
Later that evening, I held back tears as I rehashed each moment of the hopeless code. Had I moved too fast? Had I deprived my patient of too much oxygen while fumbling to ventilate? Did I over sedate him? I will never know the answer to any of these questions.
The remainder of the night was a blur. I couldn’t sleep because I was busy with other patients. The man’s wife and family came and went. It wasn’t till the next morning that the phone calls started to roll in.
Apparently my patient had three daughters from a previous marriage who were unaware of what happened. I took three calls that morning. I told three young women that they had lost their father. I waited patiently as they broke down. As I listened to their sobbing, I remembered what it felt like to lose my father. Each call lasted less then five minutes and left an indelible mark on my soul. I had never experienced a grief so pure and innocent as those young women’s. I will always feel responsible.
And this is what the chief meant by being “hurt.” If you practice medicine long enough, you will make mistakes. You will accidentally harm people. You will work long hours and deal with the most primitive human emotions. At some point you either learn to sublimate, learn to move on, or get crushed.
When we say that someone “can’t be hurt,” we’re saying that they can work 36 hours in a row without sleep. They can deal not only with the annoyances of hospital life, but also with the fear and sadness. And still, at the drop of a dime, they can make critical decisions involving people’s lives. It also means that we learn how to be hard, learn how not to cry. We drop our emotions and sentimentality to survive. We change who we are.
When I became a physician, I unwittingly made this sacrifice for the sheer good that I could accomplish. I could deal with the stress, sadness, and culpability, as long as there was a pot of gold at the end of the rainbow – being the kind of physician my father was. I could give up the tenderest side of myself to avoid getting squashed by my experiences.
So that day, in the ICU, amidst the phone calls and grief I stood at the abyss. I could either let momentum and sadness carry me down or I could step away. At the time, I thought I was choosing life. I didn’t realize that I was lost.
I found myself again October 25th, 2004. The day my son was born.
After the ICU incident, the rest of my career had been rather mundane. I left residency and joined an internal medicine practice. My days were straightforward. I crammed as many patients into as few hours as possible to stay afloat. The malpractice crisis was a constant worry. Malpractice rates went up. Physicians were forced to see more patients in less time to cover overhead. The quality of care went down. There were more lawsuits. The downward spiral went on.
People were less happy with their doctors. I often found my patients to be angry and distrustful before they even met me. There was a constant barrage of paperwork for unknown reasons. I was repeatedly questioned by insurance companies. I rarely felt like I was helping anyone.
Physicians were also changing. Because of the lower income, decreased respect in the community, and family obligations, they were becoming less responsible for their patients’ well being. The days of your doctor meeting you at the emergency room late at night were long gone. Most young physicians believed that after the workday was over, their patients were someone else’s concern.
And I thought that I was okay with all of this -- until my world radically changed with the birth of my son. When I looked into his eyes looking back at me with complete trust, the barriers that I had erected since that horrible day in the ICU came down. I could cry again. I didn’t have to protect myself anymore.
And that left me with some hard questions. Why was I staying in medicine? Why did I give up an important part of myself for a profession that promised so much and delivered so little? Where had I gone wrong?
And what did this say about the state of healthcare today? I had come into the profession with the hopes of helping humanity. I trained at some of the top institutions in the world. I received various awards both for academic rigor and for clinical acumen. I was considered bright, caring, and hardworking. These are qualities that society expects from great physicians. But they are not enough.
The day of my son’s birth, the story that I had told myself about my life once again shifted. My father’s death had brought me to a profession that I would no longer pursue. As my son was born, I would leave medicine. I would make the change in time to teach him what is really important. I had changed once before, for the worse. This time I would be restored to my former self.
But in my heart of hearts, I eventually told myself something completely different. Maybe I truly was meant to be a physician and help humanity. Maybe it wasn’t me but medicine that had changed.
As the years pass and my son grows older, I continue to practice today. I realize that who I am is a result neither of my father’s dying nor of that horrible night in the ICU. They are sad tragedies that will neither define nor hold me back.
It’s time for me to take responsibility and embrace who I have become. For my son’s sake.
Posted by Jordan Grumet at 5:43 PM
Monday, February 13, 2012
As the bearer of news, I had become the target. Joe's words were innocent enough, but his tone purveyed a sense of accusation.
How could this happen so fast?
Joe rocked back and forth with his head in his hands. He looked around the office as if he had never sat on the exam table clothed in a skimpy gown; as if he had never been my patient.
His mother in law was in the hospital medical ward with a belly full of fluid carrying clumps of tumor cells enmeshed in vital organs.
She was dying.
There were very few people as saintly as Joe. When he married his sickly wife, he also took on the care of her sickly parents. Over the years of watching them in my office, it became obvious that he had a special relationship with his mother in law.
Since Joe's own mother died when he was a teenager, his new family fulfilled his deep emotional needs. He doted over his mother in law, and stood by her during the tumultuous spiral of chronic medical problems. Years of rheumatoid arthritis had left her joints crippled and her lungs could barley expand against the iron cast of scarring and fibrosis.
So when her belly began to swell, Joe brought her to the emergency room. A Cat Scan revealed and abdomen full of fluid and tumor deposits. She was too frail for surgery, to weak for chemotherapy.
Joe didn't need to be told what to do next. He vowed to give his mother in law the dignity he was to young to give his own mother. He would let her die in peace. He would protect her from the long arm of medical intervention and cushion the mighty fall of the living.
Although his anger toward me had cooled, he would never look me in the eye again. I helped arrange hospice care, and moved her to a nursing home down the street. A week later, I stood above her as I told Joe the time was near.
He thanked me for all I had done.
At that moment, I didn't realize that I would never see him again.
Joe and his wife disappeared from my outpatient practice. It took a few months to realize something was wrong. I left a message on his cell phone but he never responded. I was hoping to at get a fax number to forward his medical records.
I guess I can't blame Joe for his reaction. Sometimes, even when everything is done right, the sadness and anger are still insurmountable. Joe associated me with the loss of his loved one. A loss that resonated deeply for someone who had lived without a mother for so long.
I hope to run into Joe one day on the street and tell him how sorry I am for his pain. I find it difficult to think about him still harboring such feelings toward me.
It's hard enough to lose a patient you care for,
to lose a whole family is devastating.
Posted by Jordan Grumet at 9:14 AM
Saturday, February 11, 2012
What happened to the docs who used to take care of everything.
Although I knew that the abscess was best handled by a surgeon, I too felt a a strange sense of longing. How many times did I have to hand off care to another more specialized doctor?
My patient sat quietly in his chair and stared past me at the eye chart on the wall. He labored to breath through the oxygen prongs affixed to his face. His legs were swollen and oozing edematous fluid into the kerlex wrapped around his monstrous ankles.
I was managing so many of his medical problems.
But there was a time when I handled everything.
The residents work room had a large window that looked onto a poorly lit street with various anonymous figures lurking in an out of the shadows. The VA hospital sat on the border of two equally poor neighborhoods. The residents and medical students dared not leave the safety of the parking lot or the medical complex.
It was midnight, and as a second year resident I was the most senior physician in the hospital excluding the ER attending. I sat with my feet on the desk and a stale pastry in my hand. My interns were dispersed amongst the medical floors, catching up on work from the previous day.
The buzz of the pager almost knocked me off my chair. A moment later, I was talking on the phone with the emergency room attending a few flights below the residents work room. He was almost hyperventilating.
Come quick, I need your help.
I alerted my interns, and we bounded down the steps. I burst into the the three room exam area that VA administrators called an emergency room. The patient was a middle aged man in extremis holding his sternum. His chest and stomach were pumping back and forth at a respiratory rate that was too high to count. The attending was fidgeting beside him adjusting the nonrebreather mask.
As the ER physician hurriedly presented the patient to me, I looked at the vitals monitor. The systolic blood pressure read 250 and the heart rate was peaking at well over 100. I barked a series of orders at the nurse.
Start a nitro drip, give a 80 of lasix and 5 of morphine stat.
I knew immediately what was wrong. The patient was in flash pulmonary edema from a hypertensive crisis. I had seen it before. Over the next ten minutes, I threw just about everything I had at him. Eventually his respiratory rate slowed. He unclenched his hands and sat comfortably in bed.
I handled it because I had no choice.
There was no else to.
Over the years my medical knowledge and experience have expanded exponentially. Yet, the most difficult lesson has been to know when you need help.
I am no longer a resident stuck in a VA hospital. There's ample backup available.
And I have no problem asking for help when I need it.
Posted by Jordan Grumet at 6:01 PM
Thursday, February 9, 2012
I believe that we each inhabit a space that forms a delicate balance in the universe. Birth and death disrupt this balance. Sometimes the shift is imperceptible to those who aren’t there. Occasionally, however, the aftershocks are felt at a distance by others.
My mother described it as a severe pain that developed suddenly in her hand. It was strong and swift. Minutes later the hospital called to say my father had collapsed. One of my patients told of severe chest pain that occurred just as his wife was dying from a heart attack. He didn’t know that she was dead yet. He had never felt this type of pain before and never would again.
I hear of these occurrences frequently and have come to believe they are real. It gives me hope that, alongside the medical knowledge and science we practice daily, there is an energy or force that connects us as human beings. This force is especially strong between those that love each other. And when a person dies, he sometimes sends a parting message to those who care.
But what is the nature of these “messages”? Are they unspoken utterances between parting lovers or a last goodbye to family and friends? And what if there are no family and friends? Is the message still sent? Does it fall on deaf ears?
Mr. Walters had been coming to my office for years. He was in his eighties and in poor health. The decline was a slow progression. It started when he was diagnosed with a lymphoma that grew rapidly in his pelvis. Surgery, radiation, and chemotherapy had eradicated the tumor but left him with severely obstructive kidney disease. By the time I met him, the stents placed to open his urinary system had begun to malfunction. No matter how many procedures the urologists performed, his kidneys were failing.
His physical condition was also deteriorating. He maneuvered gingerly around his apartment. There were no family or friends to take care of him. He lived a solitary life. His only connection was a distant niece he saw infrequently.
I tried to have many conversations about the end of life. As his primary care physician and only advocate, I needed to make sure that I knew his wishes. Unfortunately, he didn’t like to talk about such things. His usual response was similar to other men in his age group: “Doc, do whatever you think is best!”
Eventually I convinced him to move to a nursing home. He sustained a number of falls and was no longer able to cook or clean for himself. He was placed on dialysis when his kidneys failed.
Every few months he would get admitted to the hospital for a kidney infection. Each time I walked into the room, his face would light up and he would thank me for coming. We both knew that his time on this earth was limited.
I saw him one last time before he died. He was admitted to the hospital with low blood pressure and another urinary infection. He was on a ventilator.
I knew through our brief conversations that short term life support was okay, but he did not want to be kept alive for a prolonged period. As the days passed it became clear he was dying. I called his niece. She would come to visit him and then life support would be withdrawn.
As I drove home that day, Mr. Walters was the farthest thing from my mind. His niece was arriving soon and then he would be extubated. The ICU staff could manage everything. I had just picked up dinner for my wife and son and music was playing loudly in the car. It was a beautiful day and the windows were open. I felt invigorated.
Then all the sudden it happened.
It came over me like a thunderstorm. One minute I was happily bouncing to the music, and the next I wanted to cry. I pulled the car over, closed the windows, and wept.
I couldn’t stop thinking about Mr. Walters and how much he must have seen in his eighty years. He lived through world wars and depressions. He experienced the sadness of the holocaust and the fear of nuclear annihilation. He likely loved and lost many times. He had eighty years of constant motion and now he lay quietly in a hospital bed, gone.
As quickly as the burst of emotion came, it left. I wiped my eyes and turned on the car. Moments later, it was no surprise that my cell phone rang. It was the ICU; Mr. Walters had just passed away.
As the years go by, I often think of Mr. Walters. In his dying moments he sent a message to the world and I was lucky enough to receive it.
Posted by Jordan Grumet at 5:42 PM
Wednesday, February 8, 2012
Privately, they argued about the different approaches. One saw the world in terms of black and white, while the other was steeped in a foggy haze of gray. The professor felt that patients needed to be scolded and prodded into the preferred direction. He heard the rumblings of patient empowerment and had quite a cackle in the physicians lounge with his like minded colleagues.
If they are so empowered, why do they come whining to us?
The professor had no problem laying down the proverbial law to his patients. In fact, it was during one of these impromptu brow beatings of a young lady with morbid obesity that he felt the first twinge in his chest. It was fleeting like a wisp of air that came and went by the time one was able to think about it.
The professor dismissed such symptoms. He was healthy to the bone and wouldn't let such musculoskeletal aches and pains bother him. As the days passed he randomly rotated his shoulders and expanded his chest in order to recreate the discomfort he felt in the exam room. If he could reproduce the symptoms then surely it must not be his heart. But nothing happened.
A few days later a sharp stabbing thorn pierced his sternum while talking on the phone with a colleague. The professor almost dropped the receiver but recovered when the sensation dissipated. As the day progressed, the pains began to increase. They came more frequently and lasted longer.
The professor muddled to rationalize his symptoms as something benign (a process which he would have highly criticized in one of his patients). He tossed and turned in bed till midnight before finally falling asleep. He awoke an hour later in a panic. He felt a crushing pressure over his chest and he gasped for air. He reached over to pick up his cell phone.
Hello 911...I'm having a heart attack!
The professor was convinced that his ride to the emergency room would be his last tenuous grasp on a life cut short in its prime. But with a little oxygen and nitroglycerin, his pain abated.
When his partner waltzed into the exam room at three in the morning, the Professor felt a moment of embarrassment before relenting to the overwhelming sense of relief. There was not a trace of mocking in his partner's voice.
You had me scared there for a moment, I hope you don't mind that they gave me a call.
He placed his hand on on the Professor's gowned shoulder and then began to examine him. Later he sat in a chair next to the gurney and reviewed the options. To his great surprise, the professor didn't mind being treated like and ordinary patient. He felt strangely taken care of and glad to have his doctor illicit his opinion.
They eventually decided on a short stay in the hospital and a nuclear stress test the next morning. The Professor fell asleep peacefully as he waited for his bed on the telemetry unit.
The stress test showed no signs of heart disease. It appeared that the Professor was more likely having a panic attack. After dressing to leave the hospital, he sat a few moments with his partner who was preparing the discharge paperwork.
He looked appraisingly at the man standing in front of him. What once evoked anger and sarcasm now seemed almost angelic. He had come to understand what patient centered care meant. The idea was to place the physician and patient on the same level. There was no need for power inequality.
To his great surprise, he had become an empowered patient. Not by his own knowledge or abilities, but rather by the respect and dignity afforded by his colleague. He had been both assured by his physician, but also allowed to participate in his own care.
On that day he vowed that he would no longer be the Professor.
He would be a student,
a student of human nature.
Posted by Jordan Grumet at 6:06 AM
Tuesday, February 7, 2012
They were bitter tears. She smiled awkwardly though the tissue as she apologized. She never expected to find herself a single mother at such a young age. I paused and allowed my patient time to collect herself.
As we sat in silence, I searched for solace. How many times had I comforted mourning spouses? Days, months, years after their partner died, the sadness remained. I would like to assure her that it would get better, but in some ways it wont. The wound will not heal. It changes, scars, and is often momentarily forgotten. But it never goes away.
Where is Harry? Did he wander off?
I looked with pity at the elderly woman sitting in the corner of the activity room at the nursing home. Her husband died a year ago. At first the staff would gently remind her that he was gone. Her face would twist into a frown and she would begin to cry, but moments later the cobwebs of dementia would cloud her insight.
When is Harry coming back?
Time wasn't measured in days or hours, her attention span could barely hold on to seconds and moments. Her internal clock was set to a time when life was better. Her husband would be back from the store in minutes, and the grandchildren were playing in the yard.
It was an isolated existence fraught with confusion.
She lived in a protected shell of memories.
All pain was temporary.
Dementia steals away memories and the ability to function. It decimates that which makes each person so unique: the experiences, the past, and the ability to hurt and mourn.
I do not envy my young patient who lost her spouse. The boundless pain she feels will corrode and rot inside of her.
But the ability to hurt is a gift.
It's the dark side of loving too much.
Posted by Jordan Grumet at 7:56 AM
Sunday, February 5, 2012
Originally, grandma was set to move into the small room next to Suzie's parents. But after his first night in the attic, Billy refused to set foot up there again. So dad lovingly wrapped grandma in his muscular arms and carried her to her final resting place. It's not like it really mattered. Grandma was bed bound and didn't know the difference.
It was a lonely summer. Unable to afford camp, Suzie's parents asked that she stick around the house and take care of her grandmother. Although she originally protested, Suzie learned to enjoy the quiet moments in the sun drenched room that became her second home.
One evening late in August, Suzie awoke to find the whispering fingers of sleep wrapped around her neck tightly. She gently tiptoed up the steps to find her grandmother staring out the window. She sat quietly in the chair next to the bed, and reached out to hold her hand. As her grandma spoke, her ancient eyes remained fixed on the moon.
Deep inside each one of us is a superhero, have courage!
Suzie laid her head on the bed and quickly fell asleep. She awoke to find her grandmother's body had grown cold. She passed during the night.
Suzie could find no better way to honor her grandmother's memory than to become a physician. And she held tightly to those last words as she struggled with the academic hurdles that only seem to multiply over time.
After two years of continuous studying, she was content to begin her clinical rotations in the hospital. But her joy was short lived. She found the pace on the wards exhausting, and her time was more compartmentalized the ever.
Her Internal Medicine rotation was particularly vexing. She labored alongside a group of residents and attendings that seemed more interested in patient disposition and discharge than health and well being.
Suzie was criticized repeatedly for spending too much time with her patients. After interviewing Mr. Smith for over an hour, she walked out of the room to find her attending rolling his eyes in the direction of the other medical students. His voice dripped with sarcasm.
Oh yeah, spend all day with a homeless alcoholic dying of cirrhosis, you'll learn alot there!
But Suzie saw the world though a different lens then the rest of her colleagues. She knew Mr. Smith as a lonely man who medicated himself with the only means available. So in her mind, the hour was time well spent.
Days later, Suzie followed her attending and residents into Mr. Smith's room for morning rounds. He was unconscious and each breath struggled past his lips as if it might be his last. The attending shook his head.
The DNR is already signed.
He turned abruptly and walked into the hallway with the residents chasing behind. Suzie's voice cracked as she spoke from the back of the crowd.
He has no family or friends, can I sit with him.
Suzie's resident became white as a sheet. The attending stopped mid step and turned back. He looked at his watch and then his eyes narrowed. He spoke in Suzie's direction without looking directly at her.
We don't have time.
As the group continued down the hallway, Suzie pealed off from the edge and hurried back to Mr. Smith's room. She walked through the door and leaned over his body and placed her lips close to his ear.
Your not alone anymore!
Suzie held his hand and waited. His chest became less labored and his body visibly relaxed. For a moment, she felt her grandmother's presence in the room as Mr. Smith drew his last breath.
Suzie had reached the pinnacle of her medical education.
The knowledge and experience would come with time.
Posted by Jordan Grumet at 5:19 PM
Saturday, February 4, 2012
The author page.
He explains this as if I should already know. Next he works on the title before beginning the body of the story. He has plans to scan the result into his mother's computer and then print several copies. Tomorrow, he imagines he will go to the Barnes and Noble and put them on display.
Later, he collects all the books in his room. He arranges his furniture to create an entrance to his new "library". He cuts out ten long strands of paper and writes "librari Kard 50 sents" carefully on each one of them.
When he's finished, he runs down the stairs to the mud room and puts on his boots and jacket. He calcualtes that if he sells all ten, he will have plenty of money to buy a toy at Target.
An hour later, he returns with the same handful of papers and frown on his face. I try not to laugh at his energetic entrepreneurial spirit.
Sometimes my son plays with old cell phones. He holds them up to his ear and paces back and forth disrupting the quite of the living room. His eyes become tense and he speaks in commanding tones. Occasionally he clicks on the icons on the screen, and tries to access the Internet.
The other evening my wife asked me if I wanted to watch a movie. I replied that I was too busy working on my manuscript of poetry, calculating next years financials for the office, and I had a few pages to return.
As I reached for my cell phone, I thought of my son tucked away soundly in his bed. On the good days, I think of his imitation as a form of flattery. On the bad, I wonder if it is me who is copying him. Maybe we both are childlike with an inflated sense of our own abilities.
Although we sometimes dip our toes and test the water, more often we jump in head first with no idea of what awaits below the surface.
And we occasionally leave the house with high experctations only to return shortly with a frown on our faces,
and little to show for our efforts.
Posted by Jordan Grumet at 3:29 PM
Friday, February 3, 2012
I take a seat in the chair next to the bed and wait quietly. The nursing home is strangely inactive so early in the morning. The sun has begun to rise and light washes over the grassy prairie outside the window.
An elderly man is sitting in the recliner beside me. He leans over to hold his wife's frail hand. She lays unconsciously next to us. As I imbibe the scene, it becomes rapidly apparent that I have little to offer as a physician. My stethoscope is impotent, my medical knowledge is transparently thin.
I stand and begin my physical examination. Not out of medical necessity, but more for the husband's comfort. There is something about the familiarity of the laying of hands that brings calm and control to an ungraspable situation.
The woman in the bed is almost lifeless. Her pulse is thready and her respirations labored. She does not respond to my voice or touch. When I finish, I stand motionlessly. My presence may be the only poultice I have to offer.
She hasn't really been herself the last few years.
Such a benign statement to describe the utter destruction of dementia. First, her short term memory flew away like a bird migrating for winter that never comes back. But she was smart enough to compensate for that. Eventually the forgetfulness metastasized to names and faces. Old acquaintances became mocking strangers.
With the passage of time, such life defining tasks as eating and bathing became unmanageable. A woman of stature and bearing was now childlike and innocent. The transition was made from husband to caretaker to babysitter.
The only respite lounged in a past littered with old photographs. They held tightly to memories of vacations and hobbies. Life as it was before the unrelenting cruelty of senescence dealt its mortal blow.
We were waiting for death.
Not the cruel arrogant taker of souls, but more the soft gentle landing place for the addled mind.
Posted by Jordan Grumet at 6:38 AM
Thursday, February 2, 2012
I have always been cognizant of the pitfalls of taking care of family and friends. I constantly worry that personal feelings will blur the lens of objectivity. On the other hand, I could see where my loved ones would enjoy knowing that their doctor has extra "skin in the game".
Little did I know that a few years later Leslie would be gone,
and I would find out in the worst way.
I couldn't help but sigh as I sat down to the large stack of papers that had collected on the desk in my absence. I stared up at the clock. One hour before my first patient would arrive.
I hugged my shoulders tightly and shuttered. After a week of tropical sun, I wasn't yet ready for the torrent of cold that came with returning to Chicago. My seven day vacation felt like an eternity. Now I was a foreigner in a foreign land.
I grabbed a pen and started to sign. Papers flew right and left as I scanned each document and affixed my eligible scrawl. Ten, twenty, thirty signatures into the pile I stopped abruptly and held up the death certificate.
As I read Leslie's name my heart dropped. Nausea bubbled up from my abdomen. Guilt and remorse wracked my chest.
My partner must have forgotten to tell me that she died when I was gone.
I should have been there!
As the years pass, I no longer differentiate between taking care of loved ones and complete strangers. My fears of losing objectivity have been replaced with reality.
The closeness and personal bonds I form with long term patients are often more durable then ones with mere acquaintances. We suffer, we socialize, and we mourn together. I no longer draw such strict lines.
I believe the covenant between patient and physician is sacred. When I accept a person under my care, I pledge that I will stand by them through good times and bad. It is my duty.
But the problem is, when you oversee thousands of patients, it's like you always have a loved one in crisis.
No matter how hard I try to prepare for each vacation, I generally return to some type of tragedy or another. And I wish I could have been there to fulfill my covenant as promised. But what is one to do? I am only human!
I really look forward to the 1-2 weeks each year I leave the practice and go on vacation.
I kind of dread them to.
Posted by Jordan Grumet at 6:41 AM