Tuesday, September 11, 2012
9/11 Repost
My dream is always the same.
It’s just another day in hell. I stand on the Bone Marrow Transplant unit. There are no windows. Suddenly the building starts to shake. The ceiling cracks letting in rays of sunlight. The ground rumbles below.
Sadness, grief, and despair spew from the floor. They rise as black lava erupting from the innards of the building and drag me to the street. I am swept forward as black death encompasses the earth and moves to envelop the sun. It carries me to the east…..always to the east.
*
I've never thrown a punch. Never been in a fight or carried a gun. So if you ask me what it is like to do battle…I only have a limited set of experiences to draw from.
I did, however, catch a glimpse of the desperation of war during residency when I spent a month in the Bone Marrow Transplant unit. I felt continuously under fire, attacked from all sides, desperate. I experienced death every day.
It wasn't just the elderly...it was also the young. Mothers, fathers, children…no one was spared!
*
The Bone Marrow Transplant program during residency was large. There were fifty patients on the unit and then twenty to thirty scattered amongst the oncology floors.
We had ten admissions a day and the same number of discharges. On average one patient died every 24 hours.
The job of taking care of these patients fell on two fellows, two residents, one attending physician, and countless dedicated nurses.
There are many beautiful life affirming stories that occur on a Bone Marrow Transplant floor.
This is not one of those.
*
I remember my last day on the unit. I spent the morning avoiding ambush. There were no codes. All our patients survived the night.
I stepped into Mrs. P’s room gingerly. Mrs. P had been in the hospital for over 6 months. She had a stubborn lymphoma that persisted despite treatment. She knew that she would never return home.
She knitted every morning as she watched the news. As with so many patients, our conversation moved from cordial greetings to a discussion of world events. I went through the motions of my examination as she recounted the most recent atrocities. They were particularly horrible today.
We did this every morning. She telling me who recently died, or was killed, or robbed. And I feigning interest although in reality I had lost touch with life outside the unit. The world could fall apart around me but I was too busy…scurrying after labs, running codes, talking to family members. Secretly trying to protect myself from the death and destruction that surrounded me.
If you listened closely to the discussions that we had every morning the essence of what was said would sound something like this:
“Doctor, I watch TV and see that in the world things are happening, and I am still here”. And dutifully I would respond, “yes, yes, bad things are happening in the world and yet, thankfully, you are still here!”
Mrs. P’s days were limited. And my days on the unit were almost over. I worked 12 hours a day, every day, for a month. My time at home, in-between shifts, was surreal. I would sleep, eat, have conversations. Mostly exhausted bridges to my next stint on the unit.
I had become a robot, a zombie.
I was withdrawing.
*
It was just another day in hell.
I sat down for rounds that morning. Mrs. P was right...things were happening in the world and strangely I couldn't’t relate. The TV above us was blaring the latest news. My attending was sitting down with his daily Tab and being prepped by the other residents.
The hum of the nursing station had reached a fevered pitch. I glanced at my progress notes and realized that I forgot to add the date and time. I looked at the clock on my pager:
10:45 AM
09/11/01
The world had instantly changed.
And it would take a good deal of time and spiritual healing to realize that it wasn’t just another day..
of death and destruction on the unit
Sunday, September 9, 2012
Is Your PCP A Palliative Care Practicioner?
I wouldn't call myself a palliative care expert. I kind of happened into the job. The nursing home had a need, and the local hospice/palliative care program didn't have the available staff. I had always been good at handling end of life and pain issues, so I stepped up. Of course, there are finer points that I could have learned in a fellowship program. I don't want to pretend that my qualifications are anything other than what they are.
But one must beg the question. Why aren't all internists and family physicians palliative care practiticioners? Don't we strive each day to alleviate the pain and suffering that walks into our exam rooms? Does it matter whether the cause is a broken arm or a metastatic cancer? And since when do we farm out end of life discussions to someone else? Someone who likely doesn't have a longstanding preexisting relationship the way we do.
Primary care has become a conveyor belt. We are no longer the chief operating officers. We have become the chief test orderer, chief prescription writer, and chief specialist consulter.
I don't think this is the way we planned it. We never wanted to hand over our autonomy. But difficult things take time. Overrun by an ever decreasing portion of the financial pot, and consumed with the moment to moment needs of documentation, most PCPs learned to survive by increasing throughput. Skimp. Delegate. Move'em in and move'em out.
We let someone else handle the time consuming difficult conversations because we couldn't afford to do it ourselves anymore.
So what is the most important job of a palliative care specialist? In my opinion, it's spending time with patients and families. Real time, where long drawn out conversations take place on ethereal topics such as quality of life, individual choices, and plans for the future.
And of course we also talk about management of pain.
I tell my patients that they have other doctors to worry about their heart failure, cancer, and COPD. I come to discuss their hopes and fears.
I have no other interest than their well being,
regardless of our health care systems current state of disease.
But one must beg the question. Why aren't all internists and family physicians palliative care practiticioners? Don't we strive each day to alleviate the pain and suffering that walks into our exam rooms? Does it matter whether the cause is a broken arm or a metastatic cancer? And since when do we farm out end of life discussions to someone else? Someone who likely doesn't have a longstanding preexisting relationship the way we do.
Primary care has become a conveyor belt. We are no longer the chief operating officers. We have become the chief test orderer, chief prescription writer, and chief specialist consulter.
I don't think this is the way we planned it. We never wanted to hand over our autonomy. But difficult things take time. Overrun by an ever decreasing portion of the financial pot, and consumed with the moment to moment needs of documentation, most PCPs learned to survive by increasing throughput. Skimp. Delegate. Move'em in and move'em out.
We let someone else handle the time consuming difficult conversations because we couldn't afford to do it ourselves anymore.
So what is the most important job of a palliative care specialist? In my opinion, it's spending time with patients and families. Real time, where long drawn out conversations take place on ethereal topics such as quality of life, individual choices, and plans for the future.
And of course we also talk about management of pain.
I tell my patients that they have other doctors to worry about their heart failure, cancer, and COPD. I come to discuss their hopes and fears.
I have no other interest than their well being,
regardless of our health care systems current state of disease.
Saturday, September 8, 2012
An Act Of Anticipation
We are motion. Finger tapping, knees shaking, continuous motion. The rhythmic beat of the marathon heart propels the legs in constant flux. The intensity of modern life grabs us by the scruff of the neck and thrusts into each new day. We over eat, over exercise, over work. Running in countless circles the path often leads back to the starting point. But the voyage is anything but futile. Futility is stillness.
And stillness is death. Except in the movies. In the movies, dying is kinetic. First laughing, then crying, some hugging, and a head falls to the side as the music begins. Boom, boom, boom, the curtain drops and the credits role.
But I have seen death in it's myriad shades and forms. More often than not, it is anything but quick. Instead, bodies lie almost lifeless in dark rooms with family members gathered in a semicircle around the convalescent bed. The second hand meanders as the visitors wait and are haunted by the slow, motionless, disturbing passage of time.
We are befuddled by the absence of initiation. So entrenched in the act of powering up, we become cataplectic at the unfolding of a life. Sometimes days pass. The barrel is loaded and griefs trigger is cocked. Waiting for death is an act of anticipation.
It is always this way. The calm before the storm. The stillness amidst turbulence.
One last moment to surface and take a deep breath,
before submerging in the deep dark ocean
And stillness is death. Except in the movies. In the movies, dying is kinetic. First laughing, then crying, some hugging, and a head falls to the side as the music begins. Boom, boom, boom, the curtain drops and the credits role.
But I have seen death in it's myriad shades and forms. More often than not, it is anything but quick. Instead, bodies lie almost lifeless in dark rooms with family members gathered in a semicircle around the convalescent bed. The second hand meanders as the visitors wait and are haunted by the slow, motionless, disturbing passage of time.
We are befuddled by the absence of initiation. So entrenched in the act of powering up, we become cataplectic at the unfolding of a life. Sometimes days pass. The barrel is loaded and griefs trigger is cocked. Waiting for death is an act of anticipation.
It is always this way. The calm before the storm. The stillness amidst turbulence.
One last moment to surface and take a deep breath,
before submerging in the deep dark ocean
Thursday, September 6, 2012
Catastrophe
I was thoroughly enjoying my Labor Day weekend before I got the phone call.
Catastrophic failure.
That's the term my office manager used to describe what had become of our EMR. Prompted by the on call physician, she dragged herself out of bed early Sunday morning and came to the office to sort things out. After a few hours of phone calls to the emergency support hot line, one thing became glaringly clear. For little guys in small private practices like ours, there is no cavalry. Apparently tech people take vacation too. There would be no solution till Tuesday morning.
Ahh...Tuesday morning. The highly anticipated prize for taking a long holiday weekend was a barrage of phone calls, "emergencies", and unhappy patients. On top of everything else, our new physician was starting that morning.
So I snuck into the office at seven am, and took stock of my surroundings. I sat as still as possible in my chair, and basked in the silence that soon would evaporate with the unbolting of our front door. Then I grabbed a pen and paper and dug in.
Unhindered by the computer usually tethered to my arm, I felt a strange sense of lightness walking from room to room. I greeted each patient with a warm smile and sat down at the desk. I forgot how much easier it is to make eye contact when your not staring at a computer screen. Sure, I was at a disadvantage without all the information at my fingertips, but the freedom to concentrate on something other than the electronic paraphernalia that cluttered the exam room was quite liberating.
An hour into my schedule, I recognized a certain joy that I hadn't felt since back in 2003 when I started using EMR's. It was the joy of concentrating every ounce of attention on my intended and preferred topic: the patient.
Needless to say, the problem ended up being as simple as a memory issue. Before I knew it, the computers where whizzing and purring again. With resignation, I abandoned my archaic writing utensils and palmed my computer. I had a few hours of charting to re do.
Kind of makes you wounder whether the computer glitch was a catastrophic failure at all.
Or was it a glimpse, a taste, of what could have been.
Catastrophic failure.
That's the term my office manager used to describe what had become of our EMR. Prompted by the on call physician, she dragged herself out of bed early Sunday morning and came to the office to sort things out. After a few hours of phone calls to the emergency support hot line, one thing became glaringly clear. For little guys in small private practices like ours, there is no cavalry. Apparently tech people take vacation too. There would be no solution till Tuesday morning.
Ahh...Tuesday morning. The highly anticipated prize for taking a long holiday weekend was a barrage of phone calls, "emergencies", and unhappy patients. On top of everything else, our new physician was starting that morning.
So I snuck into the office at seven am, and took stock of my surroundings. I sat as still as possible in my chair, and basked in the silence that soon would evaporate with the unbolting of our front door. Then I grabbed a pen and paper and dug in.
Unhindered by the computer usually tethered to my arm, I felt a strange sense of lightness walking from room to room. I greeted each patient with a warm smile and sat down at the desk. I forgot how much easier it is to make eye contact when your not staring at a computer screen. Sure, I was at a disadvantage without all the information at my fingertips, but the freedom to concentrate on something other than the electronic paraphernalia that cluttered the exam room was quite liberating.
An hour into my schedule, I recognized a certain joy that I hadn't felt since back in 2003 when I started using EMR's. It was the joy of concentrating every ounce of attention on my intended and preferred topic: the patient.
Needless to say, the problem ended up being as simple as a memory issue. Before I knew it, the computers where whizzing and purring again. With resignation, I abandoned my archaic writing utensils and palmed my computer. I had a few hours of charting to re do.
Kind of makes you wounder whether the computer glitch was a catastrophic failure at all.
Or was it a glimpse, a taste, of what could have been.
Tuesday, September 4, 2012
When Bayed To Come
She didn't know me. She didn't even know my name. Yet the stethoscope and gray coat somehow crashed through her tangled demented brain alerting her that I was a physician. She sat enthroned in a wheel chair across from the charting station at the nursing home. Her clothes were spattered with dried food, remnants of a half eaten breakfast. Like Medusa, her eyes shot daggers, petrifying me.
She waited anxiously for the nurse to leave the station before spewing her venom
Doctor! Doctor! Why don't you help me?
I looked at my watch. It was only a few minutes before my clinic across town would be starting. I had already entertained her complaints a number of times. I had put down my chart, stooped next to her patiently while she harangued me with a series of questions having nothing to do with medical care. She wanted to know where her daughter was. She wanted to know who had stolen her car (she hadn't driven in decades). She wanted to know why I hadn't visited her more often (she was not even my patient!).
Each time I explained slowly and quietly. Each time she sighed and looked at me blankly. But the moment I restarted my charting, she was at it again.
Doctor! Doctor!
Eventually I turned and left, despite her shrieks following me into the elevator. As the doors closed I felt an overwhelming sense of relief.
*
People often tell me that their doctors don't listen to them. They say that they beg for attention and are ignored.
Yet I find that hard to believe. Even the haggard, confused cries of a floridly demented octogenarian are enough to rip my heart out of my chest.
How does one not respond when bayed to come?
She waited anxiously for the nurse to leave the station before spewing her venom
Doctor! Doctor! Why don't you help me?
I looked at my watch. It was only a few minutes before my clinic across town would be starting. I had already entertained her complaints a number of times. I had put down my chart, stooped next to her patiently while she harangued me with a series of questions having nothing to do with medical care. She wanted to know where her daughter was. She wanted to know who had stolen her car (she hadn't driven in decades). She wanted to know why I hadn't visited her more often (she was not even my patient!).
Each time I explained slowly and quietly. Each time she sighed and looked at me blankly. But the moment I restarted my charting, she was at it again.
Doctor! Doctor!
Eventually I turned and left, despite her shrieks following me into the elevator. As the doors closed I felt an overwhelming sense of relief.
*
People often tell me that their doctors don't listen to them. They say that they beg for attention and are ignored.
Yet I find that hard to believe. Even the haggard, confused cries of a floridly demented octogenarian are enough to rip my heart out of my chest.
How does one not respond when bayed to come?
Sunday, September 2, 2012
A Year Of Twitter
This month is an anniversary of sorts. About a year ago, I joined Twitter. It started when I noticed that after a few of my blog posts were tweeted, my stats climbed. Thinking I could build a larger readership, I jumped in.
I took the first steps with trepidation. I signed up for NetworkedBlogs which simultaneously announced my posts on Twitter and Facebook upon publication.
It took a few days to understand Twitter lingo. At first I struggled to re post others content, or to reply to a particularly poignant post.
As time went on, I found a group of people to follow. And magically, some found me. I continued to blog as before, but my audience had deepened. Maybe I could reach a few hundred, but a retweet from some well placed social media figure could expand the number by thousands.
I met some important people. I scored a writing assignment. I was interviewed.
The changes were subtle. I never wrote that sentinel post that made me famous nor learned the trick to having endless followers. Although there were no publishers or consulting gigs waiting in the wings, my writing became more expansive and prolific. I wrote about medicine, health care reform, and life.
I learned that my spelling is atrocious and my grammar sub par. I also learned to forgive myself for such inadequacies.
The funny thing is that unexpectedly, twitter gave me so much more than I asked of it. I should say that I have never felt a part of something greater. Unswayed by religion, unmoved by high school spirit, and disconnected from university loyalty, I always pictured myself somewhat of a loner. But all of the sudden, I became part of a community.
I belong to a helter-skelter group of physicians, nurses, therapists, advocates, pharmacists and others who fall under the big tent of health care social media. Some are writers, others commentators. We are connected not by physical closeness but a tenuous electronic signal that whirrs through the ether and lands squarely on the face of our mobile phones.
We dig deeper and create content to share with each other, waiting for the next great idea to surface. Sometimes we laugh, others we cry. We scream our opinions into the vast echo chamber and rejoice that somewhere out there we are being heard.
Standing shoulder to shoulder with humanity on any given day, it took the intangible, ephemeral world of Twitter to convince me.
I am not alone.
I took the first steps with trepidation. I signed up for NetworkedBlogs which simultaneously announced my posts on Twitter and Facebook upon publication.
It took a few days to understand Twitter lingo. At first I struggled to re post others content, or to reply to a particularly poignant post.
As time went on, I found a group of people to follow. And magically, some found me. I continued to blog as before, but my audience had deepened. Maybe I could reach a few hundred, but a retweet from some well placed social media figure could expand the number by thousands.
I met some important people. I scored a writing assignment. I was interviewed.
The changes were subtle. I never wrote that sentinel post that made me famous nor learned the trick to having endless followers. Although there were no publishers or consulting gigs waiting in the wings, my writing became more expansive and prolific. I wrote about medicine, health care reform, and life.
I learned that my spelling is atrocious and my grammar sub par. I also learned to forgive myself for such inadequacies.
The funny thing is that unexpectedly, twitter gave me so much more than I asked of it. I should say that I have never felt a part of something greater. Unswayed by religion, unmoved by high school spirit, and disconnected from university loyalty, I always pictured myself somewhat of a loner. But all of the sudden, I became part of a community.
I belong to a helter-skelter group of physicians, nurses, therapists, advocates, pharmacists and others who fall under the big tent of health care social media. Some are writers, others commentators. We are connected not by physical closeness but a tenuous electronic signal that whirrs through the ether and lands squarely on the face of our mobile phones.
We dig deeper and create content to share with each other, waiting for the next great idea to surface. Sometimes we laugh, others we cry. We scream our opinions into the vast echo chamber and rejoice that somewhere out there we are being heard.
Standing shoulder to shoulder with humanity on any given day, it took the intangible, ephemeral world of Twitter to convince me.
I am not alone.
Saturday, September 1, 2012
Home
I'm sitting in front of the granite slab table in the kitchen. The house is quiet. My wife sleeps soundly in the bedroom upstairs and the kids are at their grandparents. We went to a wedding last night. The sort where you really don't know most of the participants. Yet we left well past midnight. The sun is now rising and my restless body has dragged me into the shower and down the stairs to breakfast. A bowl of cold cereal sits to my left side, and I tap at my mobile, browsing through my twitter feed. Even my tweeps are lethargic on this still Saturday morning.
Ten years ago I moved into this house. Katie and I painted nearly every wall. I remember when we brought Cameron home. Three years later, almost to the day, Leila arrived. Over the last decade we have filled the four bedrooms comfortably, finished a basement, and done countless repairs and upgrades. And at some point the wood and concrete, plaster and metal became a part of me. Our roots intertwined.
I never got over my childhood home. The home in which my father lived and died. We inhabited that space thirteen years before my mom remarried and we moved to an adjacent community.
At the time, the sense of loss was overwhelming. Not necessarily the change in friends or school, but the safety and familiarity of the walls that surrounded me.
Years after leaving, I had the most vivid dream. I was back in my childhood home. I quickly became aware of the fact that it wasn't real. I knew I was in the throws of a deep sleep and that I would awaken soon. So I consciously resolved to wander the halls one last time. I surveyed each room carefully trying to recapture the depth and breath of emotional that each space held. And then I said goodbye, and awoke to my present reality.
That's when I realized that "home" is not a physical place, but better yet a construct unwittingly created in each of our minds. Maybe like deja vu it is the fleeting sense of familiarity but also laced with an overwhelming dash of safety and remembrance.
But somehow sitting alone in the kitchen this morning as the sun rises, I realize that these artificial barriers help frame me. My love, my children, my countless books and pictures.
I am home.
Ten years ago I moved into this house. Katie and I painted nearly every wall. I remember when we brought Cameron home. Three years later, almost to the day, Leila arrived. Over the last decade we have filled the four bedrooms comfortably, finished a basement, and done countless repairs and upgrades. And at some point the wood and concrete, plaster and metal became a part of me. Our roots intertwined.
I never got over my childhood home. The home in which my father lived and died. We inhabited that space thirteen years before my mom remarried and we moved to an adjacent community.
At the time, the sense of loss was overwhelming. Not necessarily the change in friends or school, but the safety and familiarity of the walls that surrounded me.
Years after leaving, I had the most vivid dream. I was back in my childhood home. I quickly became aware of the fact that it wasn't real. I knew I was in the throws of a deep sleep and that I would awaken soon. So I consciously resolved to wander the halls one last time. I surveyed each room carefully trying to recapture the depth and breath of emotional that each space held. And then I said goodbye, and awoke to my present reality.
That's when I realized that "home" is not a physical place, but better yet a construct unwittingly created in each of our minds. Maybe like deja vu it is the fleeting sense of familiarity but also laced with an overwhelming dash of safety and remembrance.
But somehow sitting alone in the kitchen this morning as the sun rises, I realize that these artificial barriers help frame me. My love, my children, my countless books and pictures.
I am home.
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