Monday, January 30, 2017
My son is similar. His headaches and bellyaches come and go. He is famous for vomiting at any given moment and then feeling fine the next. And to think of it, we have all been under the weather lately. Our house, as so many, has been caught up in the hacking, runny nose, sore throat plague making its way though our neighborhood. Katie was lethargic and had a headache almost everyday last week.
We were all coping though. Getting better slowly as the body is wont to do. There were no emergency room visits or trips to the pediatrician. But we were all tired after a busy week and a hectic weekend.
So when the incessant beeping started, the first thing Katie did was turn down the volume on the TV. When it stubbornly persisted, I grumpily made my way down to the basement to investigate the culprit. Once in the basement, I tried to triangulate from which hidden corner the beeping was coming from. The boiler? The water heater? The fire alarm? The beeping no longer felt benign as I held my fingers to my ears to keep from permanent hearing damage. It was about when I focused on the CO sensor, that Katie called down to me.
It was the alarm company. Our Carbon Monoxide levels were too high, and they called the fire department. I rushed up the stairs, opened the house doors, and we gathered the children and coats. Katie and the kids waited in the car, and I went to the front of the house and flagged down the fire truck.
It was not a false alarm. The Carbon Monoxide level in our basement was 108 PPM. According to the paramedic, one can survive in this range for about 10 to 15 minutes. Katie's office was the next highest at 40 PPM (it usually takes about 8 hours for a person to be overcome at these levels). The kids bedrooms were in the 30's.
The Firemen shut down the boiler and the water heater and opened all the windows. Within minutes the levels had fallen to zero. We slept last night in a chilly home using our backup heating system that is meant for only half the house. Slept is a loose term, I mostly tossed and turned. We will see if the headaches and nausea disappear.
It's disturbing to think of all the possible scenarios that could have played out without the benefit of that CO detector.
Did I mention that we just installed it a few months ago?
Posted by Jordan Grumet at 7:44 AM
Saturday, January 28, 2017
Sam loved Iran. His mind could draw a straight line from a childhood spent sleeping on Hamedanian rooftops to his ascension as CFO of a multinational company. His success and wealth, however, all crumbled that day he was jailed by the henchman of a new Ayatollah who was deeply suspicious of his bosses political leanings. He won't tell us the details now, but his release, ushered by Shah loyalists at the prison, likely spared his life.
Months later, with visas obtained in Italy, Sam, his wife, and three children boarded a flight into the unknown. His wealth, property, and status remained in the country he loved. There was a pact that if they were detained at the airport, his wife and children would flee to America alone. A pact that would thankfully be allowed a single day reprieve. One of Sam's colleagues was detained the next afternoon and never heard from again.
America was not easy. Brutal in fact. Sam's position as CFO carried little weight in the US. He traveled hours on public transportation to jobs he was overqualified for to receive paltry wages. His wife, a teacher in Iran, became a manicurist. They survived day to day in a tiny two bedroom apartment. The Iran hostage crisis insured that there was no shortage of discrimination and racial slurs thrown their way.
But Sam had no time to complain. He was caught up in the most American of pastimes-providing a life for his three young children. So he found a way. When his shoe stores failed he scraped enough money together to buy an apartment building. And they had enough. Never a lavish life like he had in Iran, but there was always food on the table.
Sam's eldest daughter became a lawyer and eventually worked for the government. She had given much to her country including years of service in a very dangerous Afghanistan. It was at her invitation that three generations of his family were gathered to meet our great leader.
As he walked into the oval office, Sam adjusted his eyes to the splash of light and color, flash bulbs and smiles. A man who was forced to flee a country he loved for dubious political reasons, was now face to face with the leader of his adopted country. Ironic that he hadn't voted for this president, or agreed on so many issues. This was allowed here. Celebrated.
It had never been easy. Sam's family was nearly deported a few years after emigrating. He had been held up at gunpoint in his shoe store twice. He was a victim of far more crimes than any petty moving violation he may have committed while driving absentmindedly. His family faced discrimination of almost every stripe.
America, however, was also a country of unthinkable kindness and good intention. Her actions were often flawed, but her principles were unflappable.
At least until recently.
Sam's youngest daughter, my wife and mother of my two children, accompanied her father that day in the oval office.
He waited in line with the rest of his family. He smiled when the President stood in front of him, and offered his hand. His English still broken after all these years, his voice was almost a whisper as he spoke his given name in greeting.
I am Saeed.
Posted by Jordan Grumet at 1:22 PM
Wednesday, January 25, 2017
Every child secretly creates a story about the adult they will eventually become. A fantasy adorned with all the trappings of honor, success, and beauty. We imagine a world in which we will make a difference; touch those we come in contact with. Especially if you aspire toward the medical profession. Our particular daydream involves rushing into a room with stethoscope bouncing back and forth around neck. With expertise we bark a series of orders, maybe grab defibrillator paddles. The patient sits up and blinks. He immediately knows his life has been saved. Family members bow. The nurses swoon at our physical prowess and the medical students at our intellectual.
And then reality hits. Medical school and residency teach that heroic moments are few and far between. We learn that medicine is never a sprint, but more accurately a laborious iron man. Tenacity of spirit, a never ending curiosity, and a deep well of humanity become the characteristics we most strive towards. Our story has changed. Our identities have pivoted to a more realistic and passionate ideal. The rewards become long lasting. Durable.
The practicing physician's story is idealized into that of Kwai Chang Caine from the TV series Kung Fu. Humble and quiet, we wander the earth alone. We come upon misery and despair. We bend with the wind but don't break. Our powers are administered gently and patiently to affect injustice when possible, and to cushion the blow when not.
This is a quiet, romanticized story. We cling to it dearly during the daily blizzard of current medical existence. It creates warmth and shields against the daily fear, anxiety, and disquietude that haunts this profession.
It's easy to forget that those we administer to also have deeply ingrained narratives. And when those narratives involve illness, disaster, and death, the physicians role as protagonist is in doubt. While I have forgotten thousands of patients who have died, their family members remember me quite clearly. I am the one who told them their loved one was dying. Or gave a horrible prognosis. Or it was my phone number that came up that day on their mobile phones. The day that disrupted their lives.
It was me. In so many stories, I was the last vision before life spiraled. My words. The way I stammered or the fidgeting that they will remember as the harbinger of catastrophe.
I can't help but think that this story is wholly suffocating.
I dreamt of being a hero.
Then I dreamt of being the gentle breeze, warm and calm.
Never, never did I dream of being someone's worst nightmare.
Master Po: [after easily defeating the boy in combat] Ha, ha, never assume because a man has no eyes he cannot see. Close your eyes. What do you hear?
Young Caine: I hear the water, I hear the birds.
Master Po: Do you hear your own heartbeat?
Young Caine: No.
Master Po: Do you hear the grasshopper that is at your feet?
Young Caine: [looking down and seeing the insect] Old man, how is it that you hear these things?
Master Po: Young man, how is it that you do not?
Posted by Jordan Grumet at 8:24 AM
Monday, January 23, 2017
I wait intently as the board members rearrange themselves in their seats and look up expectantly. Silence. I wasn't going to let it be that easy. I repeat myself and pause again. This time a few tentative answers flutter up to the podium.
hospice...comfort care...end of life...giving up?
Now this is something I can work with. I clear my throat and smile broadly.
Palliative care is a philosophy.
I can't help but launch into a series of idioms. I talk of the difference between the forest and the trees. I invoke Osler's famous quote about how the great (palliative) physician treats the patient and not the disease. We talk of the sanctity of quality versus the expediency of quantity. I can see heads shaking in agreement now. The ideas are starting to sink in. I mention patient-centeredness and I can feel the the room stir. I talk of dignity. The goal is to face illness with the same dignity that we attempt to face health. The participants inhale and exhale with each word.
Palliative care is a skill set.
Palliative care is a consultative service just as a cardiology or nephrology. Board certified physicians in hospice and palliative care treat pain, nausea, anxiety, as well as a host of other symptoms. We also are skilled in advance disease planning. Counseling on end of life, and not so end of life care. Helping guide the decisions about code status and hospitalization, and timing and duration of care.
Palliative care is a team sport.
Nurses, social workers, chaplains, therapists, volunteers, and nursing assistants. Relieving pain and suffering is complex and multifaceted. It is not only a physician's domain. Each skills set brings it's own version of comfort to the suffering. But mistake me not, we all speak the same language. It is neither medicine nor religion. It's compassion.
Palliative care is not hospice.
In fact hospice is a small part of palliative care. If palliative care were a bus, hospice would be a few rows of seats in the front (or back). It is concomitant care of chronically ill patients coordinated with other specialties. One can continue any treatment they wish. Chemotherapy, surgery, hospitalization. And it is not a substitute for hospice. Hospice is a medicare benefit appropriate for up to the last six months of life for those who wish to discontinue curative treatments. It brings with it a host of services not otherwise covered by general palliative care.
Palliative care is important.
It is something you, your family, and your institution need to know about.
Posted by Jordan Grumet at 3:20 PM
Friday, January 20, 2017
Maybe worse. She was diagnosed with Glioblastoma Multiforme, a uniformly fatal brain cancer. She suffered through a stay in the same ICU she was scheduled to cover for the month. She tolerated surgery and chemotherapy.
She married her boyfriend during a prolonged stay in rehab. Her head was partially shaved in the wedding pictures. And one day, she showed up to round with our team on my second year rheumatology elective. She stayed with us the whole month. Some days she worked the entire shift, others she became fatigued and left at noon.
We laughed, we learned. Mostly we pretended she was no different than any other resident.
I assume she died long ago. Sadly I can remember her face, but no longer her name. The years have erased much. As I said, we were never particularly close.
In retrospect, we were fooling ourselves pretending she was like any other resident. That day in the emergency room she ceased being one of us, and became one of them. The sick people. The people we have dedicated our lives to treat and care for. The people we keep at arms length.
Pain and suffering are tolerable as long as there is separation. Us and them.
It works for the most part. But I can't help daydreaming that maybe she was one of those few percent who survived. That she has a family and a busy rheumatology practice in some spectacularly boring suburb somewhere.
That she came back to us.
Or that we learned how to be better at being with them.
I really wish I could remember her name.
Posted by Jordan Grumet at 3:01 PM
Wednesday, January 18, 2017
The VA was located conveniently in the middle of a food desert. The neighborhood was so crime ridden that no delivery person would agree to drive up. There was no cafeteria. So we ate bear claws. Sometimes, during a thirty six hour shift, for breakfast, lunch, and dinner. Or a late night snack. The only abundance greater than sugar, of course, was fear
As second year residents, we ran the show. Supervising a few interns and medical students, we covered the entire hospital. Hundreds of sick veterans with every imaginable disease. More often five or six of them at once. We had no backup. No support. The patients got sick and coded. They suffered almost every complication. But they never died. Veterans never died. They just got more sick.
It was one month out of a three year residency. The month that made me into a doctor. Upon it's completion, I had learned to stick a needle into most any human crevice. I pounded on chest after chest during endless nights of CPR. I brought blood pressures up and took them down. I admitted twenty new patients over night, covered the ICU, and still somehow had time to show up the next morning and get in line for the only breakfast that was going to present itself to me.
I still wake up in a cold sweat reliving those days. It's my most dreaded stress dream next to being late for college finals. A months experiences compressed and splayed out over a lifetime.
I will never be the same.
Since that rotation, there is nothing medicine has been able to hurl in my direction that I can't handle.
And the sight of bear claws makes me ill.
Posted by Jordan Grumet at 6:55 PM
Monday, January 16, 2017
When my dad died, I assume the contract was nullified. The overwhelming upheaval to our lives was so great, that a seven year old boy couldn't possibly comprehend the complexity of adult decision making. We were going to move and then we weren't. My dad was with us one day, and then he wasn't.
And my life was afloat in uncertainty. Stalwart in the idea of becoming a physician like my father, I struggled with a learning disability profound enough to keep me well below the level of my peers. I sat in homeroom coloring while my classmates read from textbooks. I had an army of school provided tutors as well as a private learning specialist. The picture would have been fairly bleak if I had been old enough to recognize.
But children can be unfalteringly ignorant toward melancholy. Their unfettered engines continue to run. They continue to run free.
My two memories left from that year color almost all that I am. In the living room surrounded by family, as my mother whispered in my ear that dad was gone. And months later, the day my teacher placed a textbook in front of my face and I read. Surprised, she place another. A slightly more complex. And I read. Then another. And another. The children looked up in awe as a pile of textbooks formed on the side of my desk.
My reading and writing improved so much, it was decided that I indeed could matriculate to third grade. Which was incidentally the reason my parents had planned to move in the first place. They were going to hold me back, and felt it would be less devastating if I transferred to a school where none of the kids knew me.
Years later, my mom would remarry and move us into the same district that I narrowly missed in grade school.
And I would thrive.
Posted by Jordan Grumet at 1:23 PM
Wednesday, January 11, 2017
There will be other times. During residency you will roll your eyes when you realize your co-intern is sick again, and you're up for all the admissions. You will curse the medical student who created the cockeyed explanation and scared the heck out of the frightened social admit in room 5. You might not yell. You might not lose your cool. But rage will boil over from time to time. You may let it loose on the radiology tech who is refusing to get up in the middle of the night and do your stat study.
Your path will continue even after you are done with training. There will always be plenty of culprits. The secretary who double booked your over packed schedule. The prior authorization phone tree that will waste the precious moments you could be spending with your children. The paranoid anxious patient who will put it off all day, and show up to the emergency room at midnight and awake you from a deep sleep. You will argue incessantly with the emergency room attending who will refuse to send him home and insists on observing for cardiac ischemia.
And you will find yourself yelling uncontrollably at the cowering patient who pulled you out of the examining room with the young guy with melanoma who was finally willing to talk about hospice, because she forgot to ask a question thirty minutes ago during her appointment.
When you look into her tear soaked eyes, a hard reality will come upon you. You are angry. You have been for years. Rage is constantly simmering below the surface scalding you and those you interact with.
You have truly become a doctor.
My advice is simple. Forgive yourself. Remember that that medical student who undercut you was wallowing in much the same way as you. The surgical scrub nurse had felt a hundred times the abuse from the surgeon who was still scarred from his own training. Your fellow resident was actually sick and spent all night puking in the bathroom. The radiology tech hadn't slept well for weeks. The secretary had been cursed out by the patient for not making room in your schedule. The anxious patient was suffering, and the ER attending was trying to be compassionate.
And yes, the young melanoma guy is dying and no one is dealing with it.
Then shrug your shoulders, exhale, and decide to turn the anger into love and understanding.
Life is much better that way.
Posted by Jordan Grumet at 5:28 PM
Thursday, January 5, 2017
Bob felt guilty about losing his job, but given his mother's current state, he couldn't justify taking another gig out of town. Because the Medicare days at the nursing facility had finally run out, his aging mom was forced back home. At first she was able to smile and even talk occasionally, but that was mostly gone. She mumbled from time to time. Nonsensical mumbo-jumbo. Or stared blankly.
Bob listened to his mother's distorted vocalizations as he undid her flimsy coverings He had debated whether to change the diaper or remove the bed sheets first, and settled on the diaper. The morning news blared on a TV which had been optimistically moved into the room before her arrival. She no longer could focus on the screen, but at least there was background noise.
Bob's hands moved quick and efficiently. He sometimes wondered during these long days if he should have become a nursing assistant. He was strong and able. He had the right constitution and didn't get queasy when dealing with the indelicacies of the human body.
His mom exhaled and then did something she hadn't done in months. She spoke.
Bob, Bob quit messing with those sheets. I'm dying.
Of course Bob didn't think. She has been talking out of her mind ever since leaving the hospital. He secured the diaper and pulled up the sheets. It was then he noticed that she wasn't breathing. Her chest was completely still. He called out for Rhonda and she rushed into the room blurry-eyed. They stared at each other for a moment, not knowing what to do. Then he called 911.
Bob new the chest compressions were futile, but allowed them for a short time before asking the paramedics to stop.
His mother was gone.
Just like she said.
Posted by Jordan Grumet at 4:34 PM
Tuesday, January 3, 2017
It will start innocently. Probably even before medical school. You will have a morbid curiosity about passing ambulances and motor vehicle accidents. Your original empathy for the victim will disappear when you begin to think of them as patients. Test cases.
The commodification accelerates during the early years of medical school. Anatomy, pathology, and physiology provide you a vocabulary to replace human pain and suffering. In gross anatomy you violate the viscera even as you hear your fellow students snigger in the background. You may not take part in their school-boy antics, but it loosens in you a certain callousness that you were previously cautious to recognize.
During the clinical years you will learn to build walls with the most rudimentary artifacts. Your first death. A mistake. Your resident standing over blaming you for the post op infection and eventual demise of a beloved patient. Your hands will scramble as you crouch amongst the linoleum of some hidden dark corner of the hospital ward, collecting dust and discarded gum. Your eyes no longer seeing, your heart trying desperately not to feel.
Residency is when you will become the master builder. Unslept nights. Missed meals. Standing on the front line wading through the intolerable excrement and blood of actual healthcare. You will learn not to cry, not to contemplate. To traipse from life to death wearing the same distracted grimace. And you will yell at that poor medical school student about the post op infection for which you secretly wonder if you caused. You now work with brick and mortar, clay and stone. Your tower rises above and beyond, up to the sky, encircling you. You are alone.
Your expertise will be so great by the time you are an attending physician, nothing will penetrate your ironclad barriers. Unlike those walls, however, your heart will be porous and ooze sadness, anger, and despair. Trapped inside that small space. Devouring you. And love, and family, and friends, and light, and oxygen will all be awaiting on the other side.
A breath away, a mile apart.
If you're lucky, you'll fall to your knees to the grit and grime and start clawing with bloodied knuckles.
Brick by brick you must undo that which you have built.
That which has been built for you.
Posted by Jordan Grumet at 12:01 PM
Sunday, January 1, 2017
It's more like when I report to you a series of normal lab results, and at the end flippantly mention a slight elevation of the white blood cell count. In my mind, it is a minor issue and likely do to that viral infection that you are recovering from. As the days pass, my words simmer and eventually come to a boil, consuming you. The elevation could be leukemia after all. You could be dying. You could be like your uncle Stew who went to the office for routine blood tests and was gone a week later. You search the Internet and are confused by what you see. You wait anxiously to repeat the blood tests four weeks later.
The white blood cell count comes back normal. You are relieved and tired. It has been a long and scary four weeks.
And I had no idea that you even suffered through this. I apologize. The problem with familiarity is that it is easy to forget perspective. I have spent the last few decades becoming intimately familiar with the ebb and flow of wayward lab results. And you have not. Frankly, I sometimes forget to look at my words, my utterances, through your eyes. The big stuff, sure. But it's the minor less tangible that escapes careful scrutiny.
God knows, there are also many other barriers. I am rushing off the phone to get back to the call from the emergency room. We are separated by an electronic elephant in the room that stubbornly inserts itself between us, and blocks my view. There are boxes and checks to be marked, and I am stuck trying to figure out whether you are a Pacific Islander while you just want to talk about your chest pain.
Per usual, I don't have adequate answers to this conundrum. Sometimes the gulf is overwhelmingly vast. Although I take full responsibility, I doubt that I will always be attuned to which of my words affect you so. Unfortunately, my experience will still color me blind from time to time.
But going forward there is one minor adjustment I will pledge to make. One way we can work together as a team.
At the end of every visit, every phone conversation, I will train myself to ask:
Tell me what questions you have? What haven't I made clear?
Then I will pause.
And you will answer.
Posted by Jordan Grumet at 6:49 AM