I have watched people die. I have pounded on the chest of a teenager as the cerebrospinal fluid seeped out of his ears after being swiped by a truck on Lake Shore Drive. I have told parents their child has died and children their parents. I have stood at my father's grave before the end of my first decade.
There is no light in premature death, no beauty, no joy, no optimism.
Yet, there is solace in this wondrous profession. I have opened my mouth to the great fire hose to have a small taste, even as the whiplash strained my neck. I am scarred and worn.
The only salve to heal these wounds is the opportunity to stem the tide of this all consuming blackness, to soften the blow.
What lies in the great divide between love and pain is basic humanity. When religion, fundamentalism, or mental illness drags ideology outside this continuum, it is easy to lose faith.
It is becoming difficult to explain to my eight year old son why we are doing such a lousy job of protecting his peers. And admittedly, I don't know how to find a middle ground with those who would unflinchingly commit such acts. How could we see eye to eye?
I will bury this terror with the humility of those who are left to deal with the aftermath.
For every one of you there are millions of us.
I may be clutching my children tightly now, but tomorrow the sun will rise.
And you'll be old news.
Tuesday, April 16, 2013
Saturday, April 13, 2013
Deliverance
I've always kinda envied obstetricians.
I remember with my first child. We laughed at the positive pregnancy test. We went to the doctors visits together. So many milestones: the first heartbeat, the ultrasound, and the kicking. The OB was like a guide walking through a foreign land. She sauntered ahead of us merrily, advising gently but firmly. Of course there were bumps in the road, there always are.
But the end points were knowable. She was not only our doctor, she was a mother herself. And when the time came, she was by our side. We journeyed together, teacher and students. Our eyes bleary at 2:30 in the morning when the pushing, sweating, and clutching were interrupted by the sweet vocalizations of a little boy.
One phase of our lives over, another was about to begin.
***
I also journey with many of my patients. The beginnings, however, are of a more bitter nature. The voyage starts with an incomprehensible diagnosis, a lopsided prognosis. And I, like Charon the ferryman, usher the lonely souls onto my boat. I steer through the uncertain fog, my hands wrapped solidly around the oar. Belting through turbulent waters, the bumps jar even when expected. The sign posts are few and hard to interpret.
I coo soothing words and hold hands, even with the realization that I am of limited experience. No matter how often I make the trip, I only get so close to the opposing shore.
The time eventually comes. We dock. The family and I huddle while the courageous soul leaps out of the boat and onto the other side.
We wave, heartbroken.
Unlike that wondrous morning with my wife and precious child,
there is only silence.
I remember with my first child. We laughed at the positive pregnancy test. We went to the doctors visits together. So many milestones: the first heartbeat, the ultrasound, and the kicking. The OB was like a guide walking through a foreign land. She sauntered ahead of us merrily, advising gently but firmly. Of course there were bumps in the road, there always are.
But the end points were knowable. She was not only our doctor, she was a mother herself. And when the time came, she was by our side. We journeyed together, teacher and students. Our eyes bleary at 2:30 in the morning when the pushing, sweating, and clutching were interrupted by the sweet vocalizations of a little boy.
One phase of our lives over, another was about to begin.
***
I also journey with many of my patients. The beginnings, however, are of a more bitter nature. The voyage starts with an incomprehensible diagnosis, a lopsided prognosis. And I, like Charon the ferryman, usher the lonely souls onto my boat. I steer through the uncertain fog, my hands wrapped solidly around the oar. Belting through turbulent waters, the bumps jar even when expected. The sign posts are few and hard to interpret.
I coo soothing words and hold hands, even with the realization that I am of limited experience. No matter how often I make the trip, I only get so close to the opposing shore.
The time eventually comes. We dock. The family and I huddle while the courageous soul leaps out of the boat and onto the other side.
We wave, heartbroken.
Unlike that wondrous morning with my wife and precious child,
there is only silence.
Friday, April 12, 2013
How Long Has It Been Since You Spent Quality Time With Your Doctor?
I'm going to be a little nondescript here.
The other day I saw a patient in the hospital. I was covering for a partner. The patient was gravely ill. There were many decisions to be made, surgeries to be planned, and antibiotics to be given. Of the fourteen days in the oncology unit, I may have be the rounding doc once or twice.
As the situation worsened, the relationship between the patient, family, and medical staff had begun to decline. Although I assessed the patient and wrote my billable note in the morning, I couldn't help but feel that there was much more to be done. Decisions were being left open ended, and many of the realities of diagnosis and prognosis were ignored like that annoying friend that one never acknowledges in public.
As luck would have it, a number of cancellations in my schedule left my afternoon completely free. So I made a few phone calls and gathered the family. I walked into the room and sat down comfortably on a chair, and looked up at all those anxious faces.
Tell me about it.
I didn't move for nearly two hours. I waited patiently on phone calls, bathroom breaks, and pillow adjustments. When I emerged from the room, the plan was completely different. Surgeries were cancelled, antibiotics stopped, and a modicum of peace was restored to an otherwise hectic situation.
The patient/family didn't need more medical care. They didn't require an xray or a brain scan. They needed an ear to listen, and an experienced voice to help guide them.
This type of interaction takes time. It also saves the healthcare system a boat load of money.
Healthcare reform, meaningful use, quality reporting, etc, etc...what could possibly go wrong?
Well, how long has it been since you spent quality time with your doctor?
The other day I saw a patient in the hospital. I was covering for a partner. The patient was gravely ill. There were many decisions to be made, surgeries to be planned, and antibiotics to be given. Of the fourteen days in the oncology unit, I may have be the rounding doc once or twice.
As the situation worsened, the relationship between the patient, family, and medical staff had begun to decline. Although I assessed the patient and wrote my billable note in the morning, I couldn't help but feel that there was much more to be done. Decisions were being left open ended, and many of the realities of diagnosis and prognosis were ignored like that annoying friend that one never acknowledges in public.
As luck would have it, a number of cancellations in my schedule left my afternoon completely free. So I made a few phone calls and gathered the family. I walked into the room and sat down comfortably on a chair, and looked up at all those anxious faces.
Tell me about it.
I didn't move for nearly two hours. I waited patiently on phone calls, bathroom breaks, and pillow adjustments. When I emerged from the room, the plan was completely different. Surgeries were cancelled, antibiotics stopped, and a modicum of peace was restored to an otherwise hectic situation.
The patient/family didn't need more medical care. They didn't require an xray or a brain scan. They needed an ear to listen, and an experienced voice to help guide them.
This type of interaction takes time. It also saves the healthcare system a boat load of money.
Healthcare reform, meaningful use, quality reporting, etc, etc...what could possibly go wrong?
Well, how long has it been since you spent quality time with your doctor?
Monday, April 8, 2013
Fear Is Like Ice Cream
My mobile rings at least fifty times a day My pager buzzes double that. I'm stopped in the hall and accosted by doctors, nurses, patients and families. And most of the questions are mundane: an adjustment of the coumadin dose, a formulary change for the antibiotic. Thousands of daily decisions reasoned through years of experience and practice. This is the life of the modern day Internist.
Yet, I can't help but admit that I'm always waiting for the other shoe to drop. Each ring, each buzz, carries the possibility of disaster. Will it be the ER with a hypotensive octogenarian, or the nursing home reporting a patient has been put on a nonrebreathing mask. Or worst of all, a young person with real chest pain and shortness of breath.
I'd be lying if I said it didn't have an affect. Fear, to me, is like ice cream. No matter how often you taste it, you can't help but quiver each time the frozen tundra meets your lips. Unfortunately, the Pavlovian nature of the human conscious can be quite indiscriminate. Sometimes we react to the stimulus in the absence of need. My body jumps awake to the vibrating pager clipped to my waste. I yell into the phone at the poor nurse reporting a skin tear or fall.
This reality can be tiring. The over stimulation of the senses and lack of sleep mean that surprises at the end of the day can be particularly challenging. So when my phone rang this afternoon while waiting for my daughter to finish her ice skating practice, I jerked to attention and fumbled to pick up.
It was Mrs. Morris calling for the third time to inquire about her husband's place on the transplant list. I reflexively began to explain again how, as the internist, I had very little power to dictate how long it would be. But she couldn't wait for my soliloquy to end and cut me short.
Dr. Grumet, Dr Grumet...he got a liver. He just left recovery!
For once, the sound of the other shoe dropping didn't startle me.
It brought me joy.
Yet, I can't help but admit that I'm always waiting for the other shoe to drop. Each ring, each buzz, carries the possibility of disaster. Will it be the ER with a hypotensive octogenarian, or the nursing home reporting a patient has been put on a nonrebreathing mask. Or worst of all, a young person with real chest pain and shortness of breath.
I'd be lying if I said it didn't have an affect. Fear, to me, is like ice cream. No matter how often you taste it, you can't help but quiver each time the frozen tundra meets your lips. Unfortunately, the Pavlovian nature of the human conscious can be quite indiscriminate. Sometimes we react to the stimulus in the absence of need. My body jumps awake to the vibrating pager clipped to my waste. I yell into the phone at the poor nurse reporting a skin tear or fall.
This reality can be tiring. The over stimulation of the senses and lack of sleep mean that surprises at the end of the day can be particularly challenging. So when my phone rang this afternoon while waiting for my daughter to finish her ice skating practice, I jerked to attention and fumbled to pick up.
It was Mrs. Morris calling for the third time to inquire about her husband's place on the transplant list. I reflexively began to explain again how, as the internist, I had very little power to dictate how long it would be. But she couldn't wait for my soliloquy to end and cut me short.
Dr. Grumet, Dr Grumet...he got a liver. He just left recovery!
For once, the sound of the other shoe dropping didn't startle me.
It brought me joy.
Saturday, April 6, 2013
Heaven And Hell: Portraits Of An Alzheimer's Ward
The lanky gentleman propels himself forward in a wheel chair towards the nursing station. Crumbles of food fall from his chin and land on his old tattered flannel shirt. He stops, as he is wont to do, at the half door that is controlled by a keypad. He peers over and spies a staff member sitting at the desk in front of an open chart.
I'm hungry, get me some food!
The staff member lifts his head for a moment and returns to his work. If one witnessed this solitary reaction in isolation, it would be assumed that this is a cold and ineffectual haven for the misplaced. But in view of the repetitive nature of this event, it starts to become more clear. This is the fifth request that has been made in the last half hour. The emergency stock of cookies and crackers has already been used up. The wheel chair backs up for a moment and then pushes forward crashing into the door. The series of epithets and racial slurs that follow is enough to make even the most staunch observer blush.
#%#*&#%%%%#!!
A string of panicked words in a foreign language fly out of the mouth of a ancient woman cloistered in a room a few doors away.
Ayudame, ayudame, ayudame, ayudame...ayudame, ayudame, ayudame.
The tone rises and falls. Sometimes the lilt of the voice suggests a question. Others, it's purely a statement of wrath. Occasionally, a moment of silence interjects until the rabble starts over again. It will go on like this all day. So long in fact, that her voice will weaken and become raw. Silence will follow only with the sweet respite of sleep.
Half way down the hall a smallish man sits in a over sized chair placed between doorways. His body limply melts into the cushion, and he weeps uncontrollably. A tall thin Asian woman towers above him draped in over sized pink scrubs. Her cart of medicines has been pushed to the side, and her hands gently reach out to his sorrowful cheeks. She clucks like a mother hen, and gingerly wipes the tears from his eyes.
Oh Harry, Don't cry. Don't cry
Day after day. Year after year.
Only the faces will change.
I'm hungry, get me some food!
The staff member lifts his head for a moment and returns to his work. If one witnessed this solitary reaction in isolation, it would be assumed that this is a cold and ineffectual haven for the misplaced. But in view of the repetitive nature of this event, it starts to become more clear. This is the fifth request that has been made in the last half hour. The emergency stock of cookies and crackers has already been used up. The wheel chair backs up for a moment and then pushes forward crashing into the door. The series of epithets and racial slurs that follow is enough to make even the most staunch observer blush.
#%#*&#%%%%#!!
A string of panicked words in a foreign language fly out of the mouth of a ancient woman cloistered in a room a few doors away.
Ayudame, ayudame, ayudame, ayudame...ayudame, ayudame, ayudame.
The tone rises and falls. Sometimes the lilt of the voice suggests a question. Others, it's purely a statement of wrath. Occasionally, a moment of silence interjects until the rabble starts over again. It will go on like this all day. So long in fact, that her voice will weaken and become raw. Silence will follow only with the sweet respite of sleep.
Half way down the hall a smallish man sits in a over sized chair placed between doorways. His body limply melts into the cushion, and he weeps uncontrollably. A tall thin Asian woman towers above him draped in over sized pink scrubs. Her cart of medicines has been pushed to the side, and her hands gently reach out to his sorrowful cheeks. She clucks like a mother hen, and gingerly wipes the tears from his eyes.
Oh Harry, Don't cry. Don't cry
Day after day. Year after year.
Only the faces will change.
Thursday, April 4, 2013
Brinksmanship
I hate it when I think of the best retort ten minutes after the conversation has ended...
She had enough. Her son said many times that he didn't want to live this way. Intubated, disfigured with tubes and lines, and riddled with small satellites of cancer throughout his body, he was no longer recognizable. Her voice was unwavering.
Remove the tube.
It was the right decision even though there were signs of improvement. The last vestiges of sepsis had pushed the kidneys into oblivion. The lungs moaned against the ventilator and refused to open. Yet the fever had resolved and the white count was trending back towards normal.
I huddled with the staff and prepared the orders for the morphine and ativan drips. I finished my note and turning the corner, I almost ran smack into the oncologist. She had seen my charting on the EMR, and rushed over to talk to the mother. She was hoping to convince her otherwise. She addressed me before she entered the room.
How come we push people off the building with chemo and then pull away the safety net right as they are hurdling towards the ground and need us the most? Withdraw care? He is just starting to improve!
I was so stunned, I didn't know how to answer. Minutes later the mother shook her head as she listened. She reasoned out loud.
So we pull him from the brink, what then? How are you going to fix the rest?
The oncologist left the room and returned to her clinic, beaten but resigned. The breathing tube would be removed despite her objections.
Sitting in my office moments later, I couldn't help but think the oncologist had it all wrong. Dying from cancer can be like falling off a building. Without interference, one dies instantaneously, no harm no foul. But sometimes we doctors pull out our flimsy tarp at the last minute.
The canvas defies acceleration and hinders death briefly, but doesn't fully cushion the fall. Bones break and vertebrate snap.
The miserable soul then lies prostrate for days on a ventilator in the ICU.
Awaiting the certainty of death,
in the most inglorious fashion.
She had enough. Her son said many times that he didn't want to live this way. Intubated, disfigured with tubes and lines, and riddled with small satellites of cancer throughout his body, he was no longer recognizable. Her voice was unwavering.
Remove the tube.
It was the right decision even though there were signs of improvement. The last vestiges of sepsis had pushed the kidneys into oblivion. The lungs moaned against the ventilator and refused to open. Yet the fever had resolved and the white count was trending back towards normal.
I huddled with the staff and prepared the orders for the morphine and ativan drips. I finished my note and turning the corner, I almost ran smack into the oncologist. She had seen my charting on the EMR, and rushed over to talk to the mother. She was hoping to convince her otherwise. She addressed me before she entered the room.
How come we push people off the building with chemo and then pull away the safety net right as they are hurdling towards the ground and need us the most? Withdraw care? He is just starting to improve!
I was so stunned, I didn't know how to answer. Minutes later the mother shook her head as she listened. She reasoned out loud.
So we pull him from the brink, what then? How are you going to fix the rest?
The oncologist left the room and returned to her clinic, beaten but resigned. The breathing tube would be removed despite her objections.
Sitting in my office moments later, I couldn't help but think the oncologist had it all wrong. Dying from cancer can be like falling off a building. Without interference, one dies instantaneously, no harm no foul. But sometimes we doctors pull out our flimsy tarp at the last minute.
The canvas defies acceleration and hinders death briefly, but doesn't fully cushion the fall. Bones break and vertebrate snap.
The miserable soul then lies prostrate for days on a ventilator in the ICU.
Awaiting the certainty of death,
in the most inglorious fashion.
Tuesday, April 2, 2013
Healthcare's Dumping Ground?
I couldn't really blame the social worker. He was just doing his job. The SNF unit connected to the hospital was full of flailing patients. So he thought he would ask for a palliative care consult (after getting an okay from the primary team). It was his third request of the day. He spoke slowly as he tried to untangle the twisted path the patient had taken.
Dr. X was managing poor old failure to thrive before he came to the hospital. But then Dr. Y, the hospitalist, admitted him and treated the urinary tract infection. Dr. Z was covering Dr. W on the cardiology side. And of course Dr. S, the oncologist, was giving chemo before he landed here.
My head started to swirl as I waived him away and ambled back to the nursing station. This was another complex patient with multiple doctors and few answers. I reviewed the chart and then went to the room and began my exam. He was an elderly, confused, chronically ill gentleman with labored breathing. He was unable to communicate effectively.
I left the room and called the daughter. She hadn't spoken to any of the doctors in awhile. She was hoping to meet later in the day to talk. I hung up and paged the nurse practitioner who covered the hospitalist patients in the SNF. Even a move down the hallway ended in a hand off to yet another provider.
It was just as I expected. Doctor X didn't come to the hospital. Dr Y had finished his week as hospitalist and was now off for the next seven days. Dr. Z and Dr. W signed off the case since the cardiomyopathy wasn't responding to maximal therapy. And Dr. S, the oncologist said that the metastatic prostate cancer was the least of the patients problem.
So it would be me, the newly consulted palliative care specialist, who would sit down and talk to the patient's family about end of life and futility. I would start a little morphine, tweak a few medicines, and stop the ativan due to delirium.
I have to admit that it all left a sour taste in my mouth. This is just one example of many. Yes, this is what we are good at, but it also kind of makes me wonder.
Has palliative care become the last bastion of sanity in the dumping ground of today's disjointed and broken healthcare system?
Dr. X was managing poor old failure to thrive before he came to the hospital. But then Dr. Y, the hospitalist, admitted him and treated the urinary tract infection. Dr. Z was covering Dr. W on the cardiology side. And of course Dr. S, the oncologist, was giving chemo before he landed here.
My head started to swirl as I waived him away and ambled back to the nursing station. This was another complex patient with multiple doctors and few answers. I reviewed the chart and then went to the room and began my exam. He was an elderly, confused, chronically ill gentleman with labored breathing. He was unable to communicate effectively.
I left the room and called the daughter. She hadn't spoken to any of the doctors in awhile. She was hoping to meet later in the day to talk. I hung up and paged the nurse practitioner who covered the hospitalist patients in the SNF. Even a move down the hallway ended in a hand off to yet another provider.
It was just as I expected. Doctor X didn't come to the hospital. Dr Y had finished his week as hospitalist and was now off for the next seven days. Dr. Z and Dr. W signed off the case since the cardiomyopathy wasn't responding to maximal therapy. And Dr. S, the oncologist said that the metastatic prostate cancer was the least of the patients problem.
So it would be me, the newly consulted palliative care specialist, who would sit down and talk to the patient's family about end of life and futility. I would start a little morphine, tweak a few medicines, and stop the ativan due to delirium.
I have to admit that it all left a sour taste in my mouth. This is just one example of many. Yes, this is what we are good at, but it also kind of makes me wonder.
Has palliative care become the last bastion of sanity in the dumping ground of today's disjointed and broken healthcare system?
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