Monday, September 28, 2009

Happy New Year!

It's the Jewish new year. I'm not Jewish, but one of my best buddies is. Inspired by another (non-Jewish) friend, I'm going to use this time to Atone, just like the Jews. Atone, fast, then feast. I'm going to skip the last two. Unless you count a cinnamon chip scone from Panera as a feast, then I've got 2/3.

Things I'm sorry for:

1. Not calling home enough. I live so far away and I love my family so much, you'd think I'd be better at this. Sure, the time change makes it hard to call them. My 'rents and my sister go to bed fairly early. The bro's probably don't, but I don't know. I feel like I'm barging in to their lives when it might not be convenient. But Doc, you say, if it's a bad time, they'll let it ring and call you back. You, my reader, are correct. This leads me to #2.

2. Not giving other people a chance to say no. I never want to bother anyone, never want to burden them and never want to be intrusive. Thus, I never ask people to help me. This is bad, I've realized, for two reasons. A) I often need help and make myself crazy trying to do it all myself and B) People often like to help! I know I like to be helpful. I like to do things for other people, so it would stand that other people would like to do things for me. So, I'm going to try and be less self-sufficient and ask people for help when I need it.

3. Pride. I'm not a terribly prideful person, but my pride definitely gets in the way sometimes (see #2). I'll try to be more humble and if I do something stupid, I'll just own up to it. I need to laugh at myself more anyway.

4. Smell the roses. Metaphorically speaking, of course. I need to take some breaks, not work myself to death. I need to reconnect with things I love to do: drawing, making cards, camping, reading for fun. I do have a life outside of work, I just need to find it again.

A friend of my Jewish Buddy died unexpectedly and suddenly at the age of 31. I new her fairly well. It was a big shock, obviously. So, it's given us both a new sense of what's important in life.

*Do what makes you happy.
*Do what brings you joy.
*Hug the people you love.
*Don't worry who thinks you're crazy.
*Be the best person you can be.

I hope I can work on my shortcomings, and I hope I can live this next year to its fullest. Happy New Year everyone!

Sunday, September 27, 2009

The Other Shoe. Or Foot. Whatever...

So, I awoke a few mornings ago at 2am. Why? Because someone had shoved a hot poker into my upper abdomen. Or so I thought. I have rarely been in so much constant pain. After 2 hours of unrelenting fire, I elected to go to the Emergency Department. Yes. I did.

[aside: I have a few cousins with aortic tears recently, and the pain I felt was not incompatable with that syndrome. I have a bicuspid aorta and may be at higher risk for aortic tears, so I didn't want to bleed out in my living room. Without that history, I doubt I would've gone in for a belly ache.]

It was interesting being a patient. I wondered why, at 4am with only 5 other people in the waiting room, did it take an hour to register me? I wondered why, with only a handful of people in the ED, did it take me an hour to be seen by a physician? Were the nurses raiding the candy drawer like they did every night about this time?

In the end, it was very educational. I had my first CT scan. I drank liquid lidocaine (which worked wonders). I got a not-helpful diagnosis of "epigastric pain" (no kidding, Sherlock). I then diagnosed myself with a stomach ulcer brought on by too many ibuprofens for the tendonitis I just got over. Seems I should follow my own advice of taking those little pills with food.

So, I'm slowly recovering, thanks to my bottle of Mylanta and omeprazole.

Physician, heal thyself. Or at least, don't kill thyself on over-the-counter pain medications.

But, another lesson learned. I'll try to be better at explaining to my patients what is going on and apologizing for the wait. Because while we may be running around behind the scenes, they are just one person waiting in a room, scared, wondering if they are going to be ok.

Tuesday, September 8, 2009

How do you explain...

My patient today is HIV+, has Hepatitis C and is on hemodialysis for his nonfunctioning kidneys.

He would like to be evaluated for a kidney transplant, which you can totally do in HIV+ patients. However, it's his Hep C that may stand in his way. It's really hard to treat Hep C after someone gets a transplant, so we try to do it beforehand. But, it's really hard to treat Hep C in patients on hemodialysis because the toxicities of the medications are so much worse.

You can do it, but the success rate isn't great. There's a new drug that should be out in about a year, but that pushes his (potential) transplant off for a year. And there's an old drug that is being looked at for a new use - Hep C treatment. It's not being tried in HIV patients yet, and he feels slighted. The patient said, "Why do they always leave us out?"

He's right. People with HIV have been marginalized in society and in medicine. However, when researchers are trying out new medications, they want to try them on the people who have the best chance of responding. The ideal patient. Patients with HIV are not ideal patients and so they are excluded from most trials.

How do you explain that to someone who feels neglected and uncared for? Who has lived through the days of Martin Luther King, Jr. Who has watched people die of HIV. Who now lives alone in a nursing home. Who probably feels the whole world is against him. I can't blame him.

I was able to convince the attending to look at the patient's case and see if we can't at least try something. We'll see what happens. Hopefully we can at least try, and if it doesn't work, well, at least we tried. And he is validated that we cared enough to try.

Wednesday, September 2, 2009

No...Thank YOU

I was in clinic today at the VA. It was a good clinic day, despite the air reeking of smoke from the California fires burning not too far away.

My fellow fellow Dr. L and I whipped through the patient list like it was butter. We were ahead of schedule (cue choir singing Handel's Messiah). We were going to leave before noon. I was going to get to my 1p meeting across town on time. Sweet.

My last pt was Mr. P. Mr. P is a new patient with a nasty foot infection. He's been suffering with it for 3 years. It hurts, it's itchy, it inhibits his mobility. He's miserable. He begins the visit by saying, "If I would've known that I would be suffering from this for this long...I would've preferred to have died in Vietnam." Oh, brother, I'm thinking. The hyperbole is a bit much.

Granted, when I looked at his foot, it did look painful. And itchy. And I could see that you might not be playing basketball with a foot like this. Mr. P, now 70 years old, bragged that he used to be very active: "I would play beach side, blacktop basketball all the way until I was 48!"

So, the attending and I concocted a plan for him - some medications, some lab tests, and an attempt to try and get a solid diagnosis for his man. Mr. P said, "I've lived a long life. If you can't help me that's ok. Just please tell me that you can't help me. Don't tell me you can help and then don't. I've lived a good life." After assuring him that we weren't about to put him in a box yet, I told him that he needed to give us more than one visit to get this nailed down. He agreed.

At the end of the visit (time check: 11:40a), he was going to put his zinc oxide cream on his foot and wrap it back up. I asked him what "support services" meant. He has mentioned that he was in Vietnam in the early 1960s, and he went over for support services and recon. He explained that he went to help the scouts gather information and to make sure they had the supplies and equipment they needed to do their job.

He told me a story. He said that he was with a group of men who were trying to move from Point A to Point B. "Like getting from here to Manhattan Beach. On foot." (Note: that's about 30 miles) I expressed shock at this, and he said, "It don't take smarts. If you can read a map, you can do it." I chuckled, because I'm pretty sure that despite my medical degree I could not navigate the jungles of Vietnam for 30 miles - with or without the threat of gunfire.

He said his group advanced to a clearing in the early morning. He felt that it was too light out to try and cross; he wanted to wait until it got dark out. However, the decision was made to go. The first 4 guys crossed without difficulty. The next group went to pass and the shots rang out. Mr. P was not shy in stating that he "was going to do whatever was necessary" to stay alive and protect the other soldiers, but he didn't know who he was shooting. He just knew that it was in a general direction.

He starteds to cut up the gauze to create a pad for his foot. He assured me that at home his dressing change goes much quicker. I assured him that there's no rush (time check 11:50a). He resumes his story.

Things quieted down and it was his turn to cross. Last. He almost made it through the clearing when the firing began again. He was hit, but he made it out. The other soldiers didn't want to leave him. "I told them that they had a job to do! They had to get to the guys that were waiting for us. They had already called in that I was injured, someone was coming. I told them to go on, I'd be fine." He said that they left, and he laid in that grass for 5 days. "They came back for me -- the helicopter, not the other guys...I never saw those other guys..." He teared up and it was clear that not only did he never see his friends again, he wasn't sure what their fates were either.

We went back to getting his wound dressed. I asked him to finish teaching me "proper" wound care. He thanked me. "For letting me bare my soul a little bit back there." He said that I was very nice for listening to him. And then he said something that pierced my heart. He said, "When God comes to get me, I'm refusing to go unless I can bring you with. Now, He can get you on your own time, but I won't let him take me to Heaven unless he'll let you in, too." I was so touched, I was speechless. I mumbled something lame, thanking him for sharing with me and hoping that his foot responded to our treatment. (time check: 12:05p, but I didn't care)

I think he came in frustrated because people weren't listening to him. Not every doctor can give 20 minutes of non-medical time to his/her patient. But, every doctor should be listening to what their patients are saying and acknowledging the pains and itches that they have. I think Mr. P was grateful that I listened, that I saw him as a person and not just a busted-up foot. What Mr. P probably doesn't realize is that I learned a lot from him today. He reminded me of how awesome it is to be a doctor -- how great a privilege it is when someone trusts you to care for them, how humbling it is when they invite you into their personal lives, and how marvelous it is to have someone look you in the eye and thank you for reaching out to them.