A Tale of Two Doctors

There are some days, especially post call days, when I lose my ability to be impartial and be aware of how I come across to people. And I’m working on it, I promise! The story that I’m about to tell you jolts me back into the reality of the human interactions that are part and parcel to what I do.

Beth* had been feeling run down for a while, and my team admitted her for an episode of bleeding per rectum. A standard chest xray done for smokers in ED showed a large mass in the apex of her right lung. She had a long history of smoking, and has lost all but one of her siblings to cancer, each with a different type. Her story is only peripheral to what was really important: how she was told.

Post-call, Dr. Castle* is an attending that you never want to deal with. He has this facade of being nice, but when I did my oral presentation of a patient by giving my cardiovascular findings before my pulmonary, he launched into a tirade; he was the first attending I’ve had that experience with. “Everybody does it the same way, every time! You should have gotten a presentation format! Learn it!” he yelled. Either way, I lost most of my respect for him in that moment, if the information gets passed on accurately, that is really the ultimate goal. At that point, he decides that we need to see Beth* and let her know what’s going on.

He walks into the room, and mind you, its early, about 7:30 am on an intermediate care unit. These people don’t get much sleep b/c vitals are required every two hours, so she’s tired and very groggy. “Good morning Beth*. I’m Dr. Castle*. How are you feeling?” She mutters a few words in reply. It didn’t seem like he even acknowledged it, but he turned to the residents and said, “We need to get in touch with her PCP (primary care physician) and let them know what’s going on.” I thought he was going to defer the news to them, but he didn’t. “We found something in your lung, and it looks like cancer.” The color drained from Beth’s* face, and she laid back in bed, and started to cry. Pat, pat, pat on the shoulder, and a, “We’ll be back to see you later,” was what happened next. Even my sleep deprived stupor, I was dumbfounded. Had that just really happened in front of me? Did I contribute to that absolutely horrible human interaction? Did I let bad news come to someone without telling them what was going to happen next?

I was so stunned, I couldn’t focus for the rest of rounds. The other intern and I went back to see her after rounds were over, and we managed to talk her through her fears.

The next day, rounds were with a different physician, Dr. Olive*, who is polar opposite to Dr. Castle*. We present the same patient to him, timing of the day was the same, but he approached the situation differently. After the presentation, he went into the room very gently, and listened to Beth, and how she was feeling. When she broke down again, he sat next to her, put his arm around her, and talked to her like a human being. They spent a good 15 minutes talking about what her options were, and what this means for her life. He was patient and kind and knowledgable. He is really what patients expect when they hear about great physicians being at this hospital.

It sounds funny, but he’s what I want to be when I grow up.

*Names have been changed

Too Young

He was yellow, almost like a highlighter. His liver was failing, and the ammonia level buildup left him intermittently coherent. He was able to recognize his daughters and that his wife, although she meant well, wasn’t the best person to make decisions for him since he was sick. His two girls sat next to the bed, and were both holding back tears. They were both very simple beauties, with great skin and beautiful hair. Gal1 didn’t seem to say much, and let her younger sister, Gal2 do most of the talking. Gal2 seemed a little more worn down than Gal1, and they were trying to decide what was best for their father.

He came into the hospital because he lost consciousness. This was secondary to his liver failure, but also something more ominous was found. The fluid collection in his lung was preventing him from breathing well. But the reason that he had the collection in the first place was due to the mass obstructing some of the vessels. The radiologist read it as 5.8 cm x 2.2 cm x 4.8 cm; in other words, HUGE. The biopsy results were not promising: squamous cell carcinoma. This man’s list of diagnoses was not something to wish on anyone:

1) Hepatic encephalopathy: due to his decades of alcohol abuse, his liver was failing, and the ammonia was affecting his brain. The only thing to prevent the damage from getting worse was giving lactulose and hoping for bowel movements, since that is the only way to remove the ammonia from the system.
2) Ascites: the liver failure also prevented adequate amounts of protein from being created. This causes fluid shifts from intravascular space (inside blood vessels) to extravascular (into the various cavities), in his case, his abdomen. He looked like a malnourished child, with skinny arms and legs and a pot belly.
3) Spontaneous bacterial peritonitis: ascites, for reasons not yet clarified, changes the ability of the gut to hold in its natural flora. Often times, a single organism makes its way into the abdominal cavity, and seeds an infection, which is extremely difficult to get rid of.
4) Squamous cell carcinoma: this mass was so large, it was unlikely that it was only in the lung. NSCLC is often associated with a particular paraneoplastic syndrome (conditions of abnormal hormone creation) which can often wreak havoc because those hormones overwhelm the natural regulatory mechanisms and often don’t response to treatment.

He wasn’t my patient, but as the oncall housestaff, he became my responsibility when the nursing manager called to tell me that his wife was threatening suit because she claimed she wasn’t getting the information about her husband’s condition. I spoke to her and calmed her down, and thought I had the problem solved. When I went to go speak to the patient and the daughters, another piece of the puzzle came into play. She was also an alcoholic, and suffering from Parkinsons, which left her dependant on controlled substances, and markedly incoherent after 6pm. Gal2 stated that she had never known her parents to ever be sober.

It took every ounce of strength for me to not cry for these girls, who had been born into a situation which is absolutely horrible. Gal1 had left home, tried to make a new start for herself, and only kept in contact with her father; she felt her mother was too selfish to look out for anyone. Gal2 had thus taken on the role of caretaker for these two people she knew as Mom and Dad, and the weight of that burden was evident on her face. Neither of the girls knew exactly what was happening to their father; the primary team had been playing telephone tag with the wife, and by default she was the decision maker since there was nothing legally to say otherwise. But the girls knew that this was not going to keep their father alive, since the only thing their mother wanted was for him to come home. Their dad was okay with me talking to his girls, so I took them to the family room so they could sit and ask whatever questions they needed to.

I made the mistake of introducing myself by my first name, instead of as “Doctor,” but when I look back on it, I think it was ok, and maybe it helped them feel like they were in the presence of another daughter. I did my best to explain all of his diagnoses, and that the majority of them were coming from his chronic alcohol abuse and dependence. They cried, and tried to ask as many questions as they could, and tried to grasp at age 21 and 24 that they would have to watch their father go through a painful course, and they were willing to take on the responsibility of being his medical proxy. When I told them about his lung mass, and its size, they tried to avoid grasping the significance. A fresh batch of sobs emanated from both, and I wish I could have just given them a hug and told them I could make it all go away. I held back my own tears, not for their father, but for them. Having a support system laced with alcohol is just beyond my comprehension. We talked for a few minutes more, and they were appreciative of the time and the explanation.

They tell us in medical school to reserve judgement, and not make comments which could be construed as insulting, but these girls deserved something. I told them that the road ahead of them was going to be really difficult, and to not be afraid to lean on each other, or to seek help if they needed it.

After getting their phone numbers to place in the chart, I said something I probably shouldn’t have as a physician, but as a person it felt like something that I needed to say. I told them I was amazed at how they carried themselves given their situation, and I told them to be extremely proud of themselves for not perpetuating the reality that they grew up with. We shook hands and said good night and I went back to document in the chart, and wish for the best for these two gorgeous girls who deserve more than they’ve gotten.

Check It At The Door…

I hate traveling at noon to another hospital.
I hate being stuck behind a driving teenager who needs to posture for his friends on the street.
I hate returning a page after 30 seconds and still having to wait for 5 minutes on hold.
I hate the drama that goes along with family.
I hate wearing clunky shoes so that my back doesn’t hurt.
I hate that I’ve lost so much money in the stock market and my old financial planners didn’t care.
I hate the fact that I’m getting old.
I can’t stand old people’s feet-it makes my skin crawl.
I hate not being able to read something other than medicine.
I hate that my life still seems to be in a holding pattern.
I hate being financially strapped.
I hate when every 3rd word your physician says is “like.”
I hate when doctors have no respect for their patients.
I hate being asked about when I’m going to get married.
I hate when patients’ families point fingers at each other when a loved one is dying.
I hate seeing the words HIV positive.
I hate meeting someone for the first time and telling them they have cancer.
But for the most part, I still love my life.

Heart

The rotation that I’m about to finish has kept me very busy, but its been an incredible learning experience. In this unit, we take care of specifically cardiac patients. They range from people who have had a heart attack, [in doctor speak it's a myocardial infarction (MI)] to people who have heart failure, due to blockages, or due to viral illness. The patients with MI tend to be ephemeral in the unit, lasting maybe only 24 hours, sometimes less. They stabilize and then aren’t really sick enough to be in the unit anymore. We send them to the floor for the tweaking of their therapy before they go home.

The heart failure patients, however, tend to linger. And when I say heart failure, I don’t mean the ones who need to go into the hospital for a day or so and come home; these heart failure patients wouldn’t be alive without the medication that is constantly dripping into their veins. Their hearts are literally incompatible with life; but through the miracle of modern medicine, we have medications that don’t whip a dying horse (like the old meds did) but they coax it to work just a little bit more efficiently. We monitor the amount of fluid in their body every four hours, and adjust doses of “water pills” such that the heart isn’t pumping more than it actually has to. It’s not an easy existence; they are confined to their rooms, hooked up to a huge number of IV poles and drips with constant monitoring, and hourly invasion of privacy such that getting sleep is nearly impossible as the nurse turns on the blood pressure cuff, takes your temperature and checks all the leads of the three different monitors to which these patients are tethered. There isn’t much to do while they are in the rooms aside from TV; the ones that have been there more than a week have loved ones bringing food, candy, the newspaper, and movies. But aside from those distractions, they sit and they wait and hope that someone else’s misfortune will be the switch that changes their life.

There was one patient who has been on the unit for the past three months, waiting for a heart transplant. He’s had his ups and downs with the medications, and some unwanted side effects. But he’s managed to keep a brave face throughout the entire ordeal. It’s been difficult to watch his decline, and see his struggle with walking recently, only because his heart couldn’t take it. He tries to remain happy, and keep his Goofy hat on, so at least he elicits a smile from the nurse or housestaff. After a month of being in the unit, he had an offer for a heart, but at the last minute, someone much sicker got it. He was disappointed, and his treatment course took a hit because of it. It’s funny how much the brain actually plays a part in what happens to the body. But for someone who is as sick as Mr. Ron* is, depression really takes its toll on what the medications can accomplish. He recovered from the depression, and the staff knew not to tell him about any more offers that he would get. Since that first one, he’s had approximately one offer a week, but there always seems to be someone who is just a little bit sicker than he is, and as such more deserving of that splendid and precious gift.

On Monday morning, I walked in to see his name not on the white board anymore. The nurse told me he had passed, but then couldn’t keep a straight face for long enough. Mr. Ron* has a new heart. Mine leapt at the news. He was still intubated after the transplant, but he was so happy, he gripped the hands of all of those involved with his care for the past three months. Today, after being extubated, he beams, and says he can’t wait to walk out of the hospital.

*Name has been changed

Being Human

These last few weeks have been much better than my first day, but I still have to grapple with the not-so-fun parts of having some extra initials and dealing with humanity in all its stages.

We, in health care, call it expiration. Everyone else knows it as dying. I was on call a few weeks ago, when I returned a page only to hear, “Mr. Blank* has passed away. I need to you to pronounce.”

Pronounce? The medical shows have it all wrong. Doctors are rarely at the bedside when someone passes. Usually the nurse after checking in on someone finds that they’ve gone. The ones that die in the hospital quietly have their last moments with dignity; that have usually elected to not have any invasive measures (DNR and DNI), and only control their pain and discomfort (CMO). Its the rare few that are in the ICU or the ED with alarms buzzing left and right to say that their time has come.

I went to the ward and had no idea what I was doing. The charge nurse was a sweetheart, and told me exactly what I needed to do to confirm the death. I felt terrible, and terrified at the same time. Regardless of my feelings, I had to enter the room of Mr. Blank* as gently as I could, because family was present.

It was dim, and quiet, except for a few sobs and sniffles coming from the room of loved ones. “Hi, I’m Dr. I’m very sorry for your loss.” I was so scared, I could barely get the words out. I tried not to shake as I walked to the bedside. He was still warm, but all other signs of life were gone. I pulled his eyelids back, but there was no reaction from his dilated pupils. His chest stayed motionless, and I heard nothing from his heart, or the sounds of breathing. I rubbed his chest, but there was no response to pain. When I went to palpate his carotid pulses, it took me a second to realize the motion I was feeling was from my thumb and not his neck; I switched my fingers and felt nothing. “He’s gone. I’m so sorry.”

A fresh batch of stifled sobs came out, and I did my best to leave the room as quietly as possible, so they would have their last parting moments with him.

I didn’t know what to do or feel. A part of me felt that I should say a prayer or something, sanctifying the death, honoring this man’s life that I didn’t know. But a part of me said that I’ve done my job, he’s at peace, and this is what he wanted (he was CMO).

Since that day, I’ve progressively dealt with more trying situations. One page I got gave me the nurse who said, “Mrs. Blue* doesn’t look too good.” Whenever a nurse says that, you stop what your doing and go to the bedside, because you have a bad situation on your hands, without fail. When I got there, Mrs. Blue was so short of breath, that putting the tube into her lungs seemed the best way to help her breathing, but she was DNR/DNI. My only option was to put on a machine that pushes air continually into the lungs, and decreases the work of breathing (BiPAP). While this seems like a great idea, it is extremely uncomfortable for a patient, and is only good for a short period of time. I called Mr. Blue, and told him how his wife was doing. Even though it was 2 am, he came into the hospital to hold his wife’s hand. When he saw the BiPAP mask on his wife, he knew that she was uncomfortable, and he choked back tears. “Can we take this off, and just make her comfortable? I’m a physician, and she wouldn’t want to stay like this.” We talked for a few minutes on his wife’s prognosis, and he consented to make her CMO. After signing the papers, I removed the mask, gave her oxygen and heard them recount their vacations and trips throughout their 48 years together. Family eventually trickled into the room, and I left to hide the fact that my eyes were welling up. She died the next day.

The most recent one seems the most senseless to me. Sami* was twenty years old, and her only vice was cigarettes. By the time she came to me however, she had undergone CPR for two hours, dropped her blood pressure so much that she needed 36 milligrams of epinephrine and four other drugs to keep her body perfused (normally 1 mg of epinephrine will make a heart double its rate). A machine was breathing for her, her kidneys looked like they had shut down, and she had done nothing wrong. We did as much as we could, family lined the hallway of the hospital, and her mother and father had no idea what happened, or what went wrong. Sami slowly stabilized herself, and by morning, she didn’t need as many drugs to keep her body alive. For the first time since she came into the hospital, she was stable enough to be scanned, so we elected to scan her brain first, to determine if she was capable of resuming normal function. Unfortunately she wasn’t. Her scan showed loss of every defining feature that makes a brain look like a brain. There was so much swelling that the normal “lump of noodles” that you should see, looked like a cantaloupe, with all the lumps and grooves (gyri and sulci) completely obliterated. The family was devastated, but they were realistic. They elected to remove life support, and Sami passed after 5 minutes in a room full of the family that she loved and loved her. All of the people involved are waiting with bated breath to find out why she died; at this point, nobody knows.

One thing that makes it easier is seeing/feeling love. Mr. Blank* had family by his bedside; he was loved. Mrs. Blue* was in a room filled with flowers, pictures, and memories. Sami* had her whole family praying for her. But Ms. Bettie* died by herself; there was nobody to notify, nobody to claim the body. And to me, that is the saddest situation in the world. I know people who claim they are ready to die by themselves, and I think they are full of crap. This is an experience that is terribly frightening, and while Ms. Bettie* was also a CMO, she didn’t have someone by her side to recognize her passing. I think to have someone hold you in their heart for at least the slightest bit of time is important, especially during death. It’s a time where it’s easy to feel the most alone. But to have someone to say you aren’t alone, you are part of something, is extremely comforting. My job of recognizing that someone has passed makes it somewhat meaningless in the grand scheme of things, because it’s part of my job. But I do it, and I cry, and I say a few words to myself to hope that they have found peace.

*Names have been changed.

My First Diagnosis

So I know that seems kind of counter-intuitive, but let me explain the hierarchy that occurs in medicine:

Attending/Hospitalist: This is the big boss. He or She is the one who gets to charge the patient and gets paid through the hospital. They are also the ones who assume the most liability as their name is one the record and their license is on the line; anything that is done for a patient is done on their behalf.

Residents: In my specialty, Internal Medicine, these are postgraduate year (PGY) 2 or year 3. They are the smarties and the tough cookies who got thru intern year. They supervise the interns and help them hone their clinical judgement such that the intern can become a resident, and hopefully an attending. They are the ones who typically make diagnoses.

Intern: Bottom of the food chain, the one that spends the most time with the patients, the one who writes notes, the one who spends the most time in the hospital and the one who has the most to learn. IE, Me

Because of this hierarchy, interns rarely get to say what to do…they most often see the patient, get the story, do the exam, and report to the resident. The resident is the one who integrates all of the information, and says, “Ok, so this is what I think, and here’s what we’re going to do.” It can be frustrating at times, but I think it’s the most perfect system: I’ve got all this jumbled, tangled web of medical knowledge that I needed to know to pass my USMLEs. But to organize it, and streamline it such that it can be useful for helping a person, that’s a skill that can only come with being an intern and learning from what the residents learned as interns.

So my last call was definitely much, much better than the first. I’m getting better at staying awake, managing on 3 hrs of sleep, and having a coherent and pleasant personality after a 30 hr call. I was called into evaluate a patient who apparently had cellulitis (inflammation of the skin and soft tissue most commonly due to infection). The night-float resident said, “It will be an easy admit, and then you can cap, and call it a night.” I didn’t know that the resident had already evaluated the patient, and put in the appropriate orders, and it was just up to me to do the admission paperwork (a monster sized packet meant to cover the ass of the hospital in every way possible).

When I went in to see the patient, however, it didn’t feel like cellulitis to me. I thought it was something else, superficial thrombophlebitis (a clot causing inflammation in one of the surface veins) and as such, I put it down on paper as the patient’s admitting diagnosis and signed my name (after which, any change is illegal). Superficial thrombophlebitis has a more commonly known evil cousin, deep venous thrombosis (DVT) which occurs more often in middle-aged and elderly people after sitting or laying down for long periods of time (plane rides, car trips). DVTs are very dangerous because that clot has a high tendency to break apart into pieces and go to the lung, causing a pulmonary embolus (PE). Pulmonary emboli can be deadly, depending on their size, because they block blood flow between the two sides of the heart and create a cascade that can often lead to sudden unexplained death. Recurrent superficial thrombophlebitis often can be a prelude to cancer, autoimmune diseases, or conditions that make the blood thicker, but only in a small percentage of cases do they actually cause a PE; however, you always plan for the worst case scenario in medicine.

While I’m getting better at this 30-hr thing, I still don’t always have my wits about me. I completely forgot to talk to the resident about what I saw and what my head and gut were telling me. The next morning, when the attending saw the patient, they agreed with me on my diagnosis, but was asking why the orders were not the appropriate ones. And that’s when I felt at my lowest. Medicine is a team effort, while I was elated that I made a correct diagnosis by myself, I definitely left the resident in the lurch. This was thoroughly bad form (yes, I apologized later), and definitely not in the best interests of the patient (but nothing bad occurred to the patient).

Nevertheless, my attending is probably one of the most non-assuming, down-to-earth physicians that a person can come across. They took the initial management hiccup in stride, and let me take the reins to say how to manage this patient appropriately. While most people would like to say that all medicine is evidence-based, superficial thrombophlebitis is one of those conditions that doesn’t have much evidence. As such, you are left with corollaries which you can draw from, and develop the “art” of medicine, instead of the so-called “science.” So I did my research, and I found evidence to say what to do for DVT, and I trusted my gut (and head) to tell me how to adjust my treatment (after confirming with my attending). My patient is doing great, and I made a clinical decision which has a real palpable impact on a person’s hospital course and how they need to be managed in the future. I can’t wait to be a PGY-2

1st Day, 1st Call

So just to clarify, traditionally, residency programs tend to start on July 1st. My program started on June 28th, and the reason for that is so that they can still give their residents 4 weeks of vacation, and give them a few days to move to wherever their fellowship program will be. And I think its pretty great because of that. Anyhow…

Not only was Monday my first day, it was also my first call. I drew the unlucky straw of first call, but also in the busiest hospital in the consortium. And after a few days of recuperation, with my next call day tomorrow, I can say for certain, people tell you residency is stressful, but they can never really convey to you the agony that you will go through that first night, and the importance of it. Lots of programs have eliminated “call” in favor of night float. My program does both–as a first year, you do night call every fourth day (q4). As a second year, you are given the reprieve of a night float team, which lets you manipulate your schedule a little be better as far as having a life outside the hospital. But as I am a 1st year/1st weeker, I think its important to know what [some] doctors go through before they are really responsible for your care. Grey’s Anatomy doesn’t really show this because this part of medicine is totally unsexy.

The day started out fine; the census was only about 6 patients. I handled 3 patients as a med student, with no problem; 6 should have taken maybe another 2 hrs tops. Boy, was I completely off my rocker! Not only did I not get to write notes on any of those patients, after 3pm, my protected time was up, and admissions began to roll in starting at 3:07pm. And did they keep on coming. As an intern, you are capped at 5 admissions per call, and 2 transfers within the hospital. But admissions take time, and a lot of it. I ate lunch at 2pm, started working on those new admissions a little after 3pm, and still didn’t finish until about 4:30 am. I did manage to sneak in dinner at about 2:30am. I thought I was getting better when I was on admission #4, but when I look back on it after regaining some sleep, my handwriting and my history taking deteriorated as the night went on. Not to mention, when on call, you have to cross cover anyone who isn’t in the hospital by looking after their patients. I was handed a list of 55 patients by the rest of the teams which I was now responsible for the entire evening/morning. I was never really comfortable saying “This is Dr.–, I was paged” but when the pager keeps ringing, it starts to become almost like catechism. And some of it is for very routine stuff, like tylenol or tums, or some pain medicine, but other times, it requires you to get up out of whatever chair you’re in, and go help the nurse deal with a patient in some way.

And then on top of this, with 1.5 hrs of sleep, we still have to write notes and round on patients the next day. JACHO has very strict rules about how long a Dr. is allowed to be in the hospital before they have a mandated rest period, and for that reason, I was doing my best to try to get in everything I needed to do before I was kicked out of the hospital at 1pm. But of course, there are things beyond your control, and one dictation I needed to do for a patient didn’t happen, because lo and behold, my dictation ID didn’t work, and would take 2-3 hours before it would. At that point, I kinda lost my ability to cope, had a bad moment.

And that’s the thing I realize that internship teaches you. Bad moments will abound, and when you’re exhausted, you’ll still be lectured about what’s important to remember about a particular patient, and pimped on the reason why you can’t/shouldn’t use one drug versus another. But the learning curve is not just exponential, it’s an exponential exponential. And these in between days have been a great learning experience. Despite that bad moment, and the ones that I know are yet to come, I cannot wait to learn more.

The Opposite of Heartbreak

“If I can stop one heart from breaking,
I shall not live in vain;
If I can ease one life the aching,
Or cool one pain,
Or help one fainting robin
Unto his nest again,
I shall not live in vain.”
- Emily Dickinson “If I Can Stop One Heart From Breaking”

Seems like the essence of medicine, no?  Ironically, its the one thing that I will never know the cure for.

[I've been wanting to write this post for a while, but today it finally seems appropriate.  I looked up the antonym for heartbreak, and the automated thesaurus came up with joy.  Joy seems like a word that is completely free of connotation, and not quite what I wanted to convey, hence the title.]

Orientation began for my program and it’s a series of long days, with lots of responsibilities that I have incurred, but in a certain way, those long days tell me one thing: this program is really out to take care of me, and make me a great physician.  The fact that they take care of a lot of things, like having an embroidered white coat, a brand new beeper, a stamp, fully paid disability and health insurance, and parking tell me that I’m extremely fortunate.  I can’t wait to get to my first rotation!

We talk about fears that we have now that the doctorate initials have been added to our name.  The one that’s the most fearful, in my opinion, is the one where I can’t do anything more for my patient than anything I have available, and their passing is unavoidable.  And unfortunately, there’s always an element of psychology that plays into whether a patient survives or passes.  Towards the end of anyone’s life, they tend to focus a lot on the heartbreaks and regrets, it makes their treatment plan all the more challenging.  Unfortunately there’s no way to reverse those heartbreaks in such a short period of time, but the only thing that you hope is that they recognize their hurdle, and hopefully take steps to find peace.

The place where this was most evident in my last life was working in the High School.  This strikingly beautiful young black woman realized that she was not going to graduate on time, and took the initiative to engage the principal, and pass the classes that she couldn’t take in summer school.  She was supposed to be attending UConn for undergrad on a full scholarship in the fall.  But her parents marriage failed, and so her heart broke, and she lost her focus in school.  Needless to say, she lost her scholarship; when I ran into her, she wasn’t joyful, but she was definitely peaceful, and determined to get the life she wanted back.

Thirty-two years is how long Mr. L* has been working with special needs children.  He starts seeing them from age five until age 21, and he helps them learn to care for themselves, maintain houses, communicate, and be contributing members of society.  But given the fact that his budget and health insurance will be cut beginning next academic year, he has opted to take an early retirement.  The staff of the High School knows how much the program will lose with him gone, and especially since these kids need continuity, it becomes even more difficult for him to make peace with his decision.  Mr. L* had not found a way to deal with his heartbreak the last time I saw him, but I sincerely hope this has changed.

Heartbreak is never anything that can be written in my PocketMedicine book, or anything that has a definitive treatment plan.  But for the lives in which I will become involved, heartbreak is an envitable force which I will have to contend with.  Hopefully my patients will be willing to meet me halfway.

My Perspective: I have had my heartbroken in the worst ways possible, my multiple people, and in very different degrees.  My favorite monologue from one of my favorite movies, “The Holiday,” states the following:

“I can understand feeling as small and as insignificant as humanly possible.  And how it can actually ache in places you didn’t know you had inside you.  And it doesn’t matter how many new haircuts you get, or gyms you join, or how many glasses of chardonnay you drink with your girlfriends–you still go to bed every night going over every detail and wonder what you did wrong or how you could have misunderstood.  And how in the hell for that brief moment you could think that you were that happy.  And after all that, however long all that may be, you’ll go somewhere new and you’ll meet people who make you feel worthwhile again.  And little pieces of your soul will finally come back.  And all that fuzzy stuff, those years of your life that you wasted, that will eventually begin to fade.”

For the first time in a long while, I feel like I’m supposed to be in this particular place, at this particular time.  And while it’s not joy, it’s not heartbreak, and it’s lovely.

* Name has been changed.

Trust

Even over the phone, Charley* had this upbeat attitude which made me smile.  ”Congratulations! Are you by chance going to become an endocrinologist?”

My jaw dropped. “I was thinking about it, but its still early to say.”

“Well good, when you get here I can show you my insulin pump.”  I was surprised that someone would be so willing to share something so personal so quickly.

When I arrived at the framer’s workshop, I stood in awe of the gilded pictures and mirrors that hung along the wall, along with the thousand other ornate empty frames that lined the room.  The workbench stood in the center of the room, with long rulers, mats, glass, and weights neatly in one corner, but still had some sense of clutter, work and fulfillment.  Charley* slowly walked in from the office area, firmly shook my hand and gave me a smile which rivaled my own in size.  He looked about 65 years old, with glasses, powder white hair and avuncular eyes.  As I took my diploma out, he pulled out his insulin pump, a small blue device which was no bigger than my BlackBerry connected to a thin piece of tubing which disappeared under his shirt.  ”This little thing has changed my life and made it so much easier for me.”  I asked about how he found out about his diabetes.

He fiddled with the weights to unroll my diploma, and stopped several times to either adjust his glasses or scratch his arm.  ”I was in the army, stationed in Germany, and that’s when I found out.  So I went through all of the headache, with the highs and lows in the sugar, but I learned how to read the signs.  Now I make sure to take my sugars seven times a day.  Even my grandkids now how to help me do it!  I hope they become doctors someday.”

I smiled.  As he looked at my diploma, he commented on the distinction, and then said, “I’ve got something else for you to too.  I found out I have Huntington’s Disease a few months ago.”

For those reading this who aren’t medical, HD is a progressively debilitating genetic illness, which makes you slowly lose function; first movement control (termed corea), then memory, and finally executive functioning (ie, reasoning and emotional control).  There is no cure, and by the time the first symptoms begin to show themselves, people usually have had children, so its hard to keep the disease in check.  It is caused by DNA expansion in a particular sequence.  This expansion increases from generation to generation and causes a protein to build up in nervous tissue, which causes the degeneration of neural function.  We don’t know what the function of the Huntington’s protein is at this point, so its hard to just stop it from being produced when the repercussions could be much more serious.

Charley is an intelligent man, and he knows the hardships that he is going to endure in the coming years.  We talked about whether his children have considered getting tested, and what he plans to do.  He’s fortunate enough to be healthy and enrolled in a clinical trial.  He tries to hide his choreic movements, which I mistook for Parkinson’s initially, and laughs about being unable to spell world backwards (a test of memory and concentration). And yet in spite of the laughter, he trusts me with his heartache, a complete stranger who walked into his life to get an inexpensive but decent frame for my diploma.

My Perspective: I have so many trust issues because of my past, I can’t even let people know what really I think because I’m afraid of being devalued or dismissed.  Trust is one of those issues that’s a catch-22, because you have to give it up in order to get it back.  And there are those rare people who can trust someone quickly, and not be wrong or feel themselves threatened in doing so.  Charley*, this old fashioned gentleman who is ready and willing to give you a little piece of himself, thanks for trusting me, I hope I can learn from  you.

*Name has been changed

A Surreal Feeling

I finally got my diploma last week, and took a good long look at it today.  Its very strange to see that the roadblocks I’ve endured come to culminate in a simple piece of paper which officially denotes my name and the degree of Doctor of Medicine in the same sentence.  But it’s also a great sense of accomplishment.  Having “Highest Honors” listed made me feel like I’ve actually found my path.  I didn’t really feel that way when I graduated college; it seemed that diploma represented the beginning of a twisty road which lead me to this point.

Even though this diploma represents the end of school, in this case, it’s definitely the beginning of the rest of my life.  Those two extra letters do change a lot of things: I am officially responsible for the well being of every person entrusted to my care.  I know for most people, having that kind of responsibility something extremely daunting, but I consider myself blessed.  I was blessed with the capable mind, I was blessed with the ability to empathize, I was blessed with a chance to make a difference and I was blessed with people around me who really looked out for me.  No journey is undertaken alone, and this one was most certainly influenced by the people I with whom I crossed paths.  So I give thanks, to those who are here, and those who have left.  My heart and my head thank you for being part of my journey.  I will try my hardest to do right by you.