i keenly observe all things

i see that you don't feel well.  your temperature is high, you look like hell, and that cough sounds like knives in your chest.  you have the flu.  you see, i do notice these things, i am very observant.  i really didn't need for you to wear those pajama bottoms and slippers in to the office today.  i would have figured it out.

my amish neighbors

when we first moved to our current home, our closest neighbors were amish.  the father was very gregarious, the mother a little more shy.  they had nine children of all ages.  we often gave the father a ride into town, usually to pick something up from the hardware store.  once, he said to me, with his typical pennsylvania dutch charm, 'so, i hear you're a nurse...'  i said, 'no, i'm a doctor.'  he said, 'oh. that's what i heard but i didn't know if you had your license and everything.'  but with the exception of those trips, and other brief neighborly exchanges, our interactions were limited.  until one night.

it was about three a.m. when the father called our house from the phone they had in an outbuilding.  when i answered, he asked me if we had any sanitary napkins, or at least that is what i thought he was asking for.  actually, he really wanted to know if i had any 'chucks,' those blue absorbent pads that are placed under patients who have anything leaking, a bladder, a wound, etc.  no, i didn't have any of those...  in my sleepy mind i was imagining that something bad, or at least messy, was happening with their cow.  but then he asked if i had a blood pressure cuff.

 okay, now i was wide awake and wondering exactly what was going on.  i was able to finally get out of him that his wife was hemorrhaging from a presumed miscarriage.  well, i got myself out of bed and down to their house pretty quickly.  she was lying in bed, and couldn't sit up without passing out.  even in the limited light of the flashlight, i could see that she was as pale as a ghost.  apparently she'd been bleeding all day and passing large clots. i felt her radial pulse and listened to her heart.  despite a blood pressure of just 80/50 supine (lying down), her pulse was slow and steady.  with that much blood loss, you would expect a very rapid heart rate.  but of course, this was a woman that spent most of her days engaged in physical labor.  i was impressed by her heart's strength and stamina.

i asked the husband if we could call an ambulance.  she was treated in our nearby ER and discharged home after declining the proposed transfusion.  the next ride we gave the father was to the pharmacy to pick up some iron pills.  when they moved away a few years later they were a family of thirteen.

in my mind, that night was not so different from all those rides to town.  our separate worlds, like two drops of mercury, momentarily joined together then split apart.  and i believe we are both the better for it.

the algorhythms of my mind

no one loves an algorithm like a doctor.  and no doctor loves an algorithm like an internist.  we have algorithms for EVERYTHING.  give us a symptom, a disease, a lab abnormality, and we've got an algorithm for it -- it's how we think.  (to give you an idea of what they look like, here is a relatively simple algorithm for a sore throat, you start at the top and work your way down... )

i spend my days navigating the algorithms of my mind.  you might have biorhythms, i have algorhythms. you don't see it, but my mind is a whirlwind of activity in that exam room.  i'm like pacman, gobbling up clues, traveling down pathways, retreating in the face of conflicting data and then choosing a new pathway, always moving, making choices at each branch point.  if the nurse notes that you have knee pain, then before i've even seen you my mind is pulling up the knee pain algorithm and lining up the data i must gather to navigate my way to a diagnosis and plan.  before you've even said a word, i've factored in your age, your history, even how you are sitting there in the chair.  then i get to hear your description of your symptoms and fill in any gaps with my own questions and exam - is the pain acute or chronic? is there swelling?  redness?  trauma?  limited range of motion?  has anything made it better?  worse?  the branch points go on and on leading me to my conclusions.  a well designed algorithm serves the purpose of providing a framework for my thoughts to follow.  an elegant, efficient algorithm is a brilliant thing to an internist like me.

there are some problems though. some algorithms are so large and complicated as to make my brain stall for a split second when i first face them.  but like standing at the entrance to a corn maze, the only way to get through is to get started.  dizziness, fatigue, abdominal pain - the possibilities are so vast!  in those cases, the initial branch points are crucial to my success.  Is it right upper quadrant abdominal pain or left lower quadrant?  Are you lightheaded like you might faint or off-balance like you might fall?  and then, some people dare to defy the mighty algorithm - they are both light-headed AND off-balance!  that throws my poor brain, momentarily, into near chaos.  but i recover and move on.  or sometimes, my patients try to trip me up by mentioning that they have also been having a shooting pain in their left leg when i am still in the middle of the headache algorithm.  i tell my patients, wait! we're not done with this first thing!  they understand.

algorithms are also the reason we cringe (hopefully on the inside only) when we have our hand on the door and are ready to leave the exam room and you decide now is the best time to mention the real reason you came in today, which is generally a more significant reason then the one you told the nurse when you called to make your appointment. (patients, please do not make an appointment for a bladder infection and then share with me at the end of your appointment that you've been having these funny chest pains that you really think are nothing but...)  i know you think maybe there is just a quick answer or bit of reassurance we can toss over our shoulders as we continue our exodus, but we are too conscientious for that.  we cannot abandon our training.  so we close the door, sit back down, and begin our journey together down the next algorithm.

we change what we hope for

when you are waiting for the biopsy report to come back, you are hoping it is not cancer.

when you have been diagnosed with cancer, you hope it is curable.

when you cannot be cured, you hope for survival.

you hope for relief of physical suffering.

ultimately, you hope for death with dignity and grace.

you hope for peace.

there is always hope, especially if we can accept that we must change what we hope for.

those simple but powerful words - we change what we hope for - were first said to me by the wife of a very sick man.  i will never forget it.  we were standing outside of his hospital room, discussing the most recent tests that showed that his cancer was not responding to our last-ditch efforts (so crudely but aptly named 'salvage therapy' in the oncology world).  i was trying, probably awkwardly in my still new role as physician, to convey my regret in giving her this news.  she reached out and put her hand on my arm and said those few gentle words.  instead of me comforting her, it was she who put my heart at ease.  how indebted i am to that kind woman for her words.  i now find myself offering those very same words to patients or family members in the face of seemingly insurmountable bad news.  together, when we have to, we will change what we hope for.

birthing with wolves

i was in my last year of medical school when i became pregnant with our first child.  i had already rotated through our ob-gyn department and my experience as a student on those wards left me with some serious misgivings about giving birth there.  i had no doubt about the overall quality of care, it would be excellent.  it was more the vibe of the labor & delivery floor at that time.  it was an older wing of the hospital, a little overcrowded, very bright, very loud.  there were residents, fellows, students, nurses, student nurses, just a whole lot of people around.  this was my first baby, and quite frankly, i wasn't entirely ready to be exposed to the world in such an unceremonious way.

so i had to do some serious thinking about where to have this baby.  home?  a friend of mine had already had three children at home with a lay midwife.  i'm not that brave, and just exactly what do you do with all the, um, mess?  the backyard?  i don't think so.  so i decided to go to the birthing center a few miles from our hospital.  immediately i loved it.  it was everything i was hoping for - warm, inviting, quiet, encouraging.  there were three licenced nurse midwives, and they were all wonderful.  initially they were a little surprised to know that i was a medical student, but they did what midwives are so gifted at doing, they took it as just one little part of who i was and continued on with their role as mentors and guides.  their posture of openness and acceptance so impressed me, that i still try to emulate it today.

that's not to say they weren't a little kooky.  they encouraged me to read these crazy books about childbirth, one of which was just waaaaaaay out there, wanting you to get in touch with your inner she-wolf and howl at the moon (or something like that).  my sister and i dubbed it 'birthing with wolves'  and had many laughs at that poor author's expense.  but i tried to absorb as much as i could from it. i didn't want to let my midwives down.

so my due date came.  and my due date passed.  i knew i had to deliver within fourteen days of that date or it was l&d for me, baby.  by day ten i was starting to panic, searching back through all those books for some practical advice on how to get into labor.  we tried it all, to no avail.  desperate times calling for desperate measures, i downed a good dose of castor oil and six hours later i was in full blown labor.  the real deal.  (here is where i should refer you back to my disclaimer about this blog not being medical advice.)

the night before, my husband and i had listened to a prairie home companion's annual joke show.  so i would occasionally rouse from my labor-induced haze to share a one-liner with the student midwife (yes, we students were everywhere) when she came in to check on me.  'two men walked in to a bar.  the third one ducked.'  silly jokes like that.  eventually she was comfortable enough to tell her own joke, just as the midwife in charge walked in.  she gave the student a puzzled look like, you know, i'm not sure that's really appropriate, but we filled her in that this was my birthing strategy - telling jokes.  they said to have a birth plan didn't they?

so we laughed our way through much of my labor, but i can't say i handled the pushing part with quite so much grace and ease.  at one point, that dear midwife got right in my face and said, beth, there's a lot of energy coming out of your mouth (such a midwife thing to say), i want you to put your head down and P U S H.  i though about telling her that i was just howling with the wolves as instructed, but the look on her face quickly stifled my impulse. and so i did just what she asked. and the rest, as they say, is history.

thank you, maureen!

differences between surgeons and internists

surgeon - green scrubs
internist - blue scrubs

surgeon - in the business of  life and death
internist - in the business of living and dying

surgeon - would never be caught dead with a stethoscope draped around his or her neck
internist - would have an identity crisis without a stethoscope draped around his or her neck

surgeon - loves a pithy aphorism (eg - all pus must be drained,  all bleeding stops)
internist - sucker for maze-like algorithms (you'll have to wait for my post on this, it's coming)

surgeon - act now, mull over it later
internist - mull over it, mull over it some more, cautious action, mull over that

the dying game

i used to go to our local senior center about once a month and give a talk.  i had a small following of mostly women and we always had a good time.  i talked about any topic they chose, and many of my own.  but after many months of pretty much the same format - me talking and then answering questions - i decided to try something new.  we would play a game, the dying game.

i first encountered this game when i was training to be a hospice volunteer.  the idea was to build empathy by having you experience just a small sense of the losses a dying person might face - loss of health, loss of mobility, loss of control.   definitely not a game you would play with dinner guests, but a game none the less.

at the start of the game, each person writes down on a piece of paper ten lists of three - three favorite people, foods, cherished objects, places, etc.  basically, the superlatives of your life.  then a basket is passed around with little slips of paper.  when it is your turn, you pick a slip paper.  it might say,  'good news!  your most recent CT scan was stable. please pass the basket to your left.'  or it might say, 'your cancer has advanced. cross three things off your list.' in that instance, you get to choose which three things you cross off.  but if your paper says 'your bowel has become obstructed.  cross off all foods.' then the choice is not yours.

the game is played mostly in silence. the basket goes around.  people are quietly whittling down their lists.  but then a slip might say, 'your illness took a sudden turn for the worse. you passed away last night.'  when that happens the person is instructed to put down their pen or pencil and turn their list face down.  it is sort of macabre, but it is meant to approximate both the physical and emotional losses of terminal illness, and even more so the loss of control we may feel at that end stage of our lives.

so i get these women to write their lists and we start passing around the basket.  initially the mood is light and they are still talking and joking. i start to wonder to myself if this was a bad idea.  but as they start crossing things off their lists in earnest, it gets quieter.  the choices get harder.  a few people die.  we don't play to the end, just long enough for everyone to have the experience.

i ask them what they felt when they had to cross something off.  anger?  sadness?  disbelief?  how did they feel when they got good news?  lucky?  hopeful?  how about guilty?  were they surprised by what they tried to save on their list?  one woman confessed that when it came down to it, she chose ice cream over a cherished photo album.  finally, a little elderly woman at the end of the table lifted her arm.  and there, clasped in her hand, was a crumpled slip of paper.  it was the first one she pulled from the basket.  it was a death slip.  she had hidden it on her lap and kept playing.  it wasn't fair she said, she wouldn't even get to play the game!  she didn't want to die!  we all laughed. we joked and told her that she couldn't cheat death.  but to me, hiding that little slip of paper probably gave her more of a sense of what i was trying to share with them than anything else that day.  death isn't fair, it isn't predictable, we aren't in control.  but, as she showed us, there's certainly no rule saying that you can't fight back!

and when exactly was that?

i swear this happens about fifty five times a day.  i am trying diligently (have i said before that i am diligent?) to take a history and it goes something like this:

me:  'when did you first notice that your leg was numb?'
patient: 'it started two weeks after my sister-in-law came to visit.'

or,

me:  'how old was your father when he died of heart disease?'
patient: 'he died when i was 52.'


you're getting the gist of this, right?

farewell, captain

i met the most interesting man last year, a true man of the sea.  he had spent most of his career as a commercial ship captain, then retired to a small town near me.  he looked like he had just stepped out of the pages of some turn of the century maritime novel.  he had brilliant blue eyes, a shock of white hair, and that cut-to-the-chase but jovial manner you would imagine a captain to have.  but he also had terrible lung disease.  at the time that we became acquainted, he was doing poorly.  fortunately, his wife, who was younger than him and in very good health, was able to take care of him well. shortly after i met him, he insisted that his wife come in for a physical. these two were generally not doctor people, so she did so reluctantly.  she was fine.

months went by and i did not see them. but i just learned that he died recently, at home, with his wife at his side.  i realize now that his insistence on her having a physical was because he wanted to know that she was okay before he left her, before he said his final goodbye.

will you be removing my gall bladder?

i saw a woman with intermittent right upper quadrant abdominal pain very suspicious for a gall bladder problem.  we ran a confirmatory test and i recommended that she have her gall bladder removed.  just to give her an idea of what to expect, i described the surgery to her in very general terms.  she then asked, 'are you going to remove my gallbladder?'  i said sure, now if you'd just lie back and stay still...

good lord, no!

actually, i told her if she ever saw me coming toward her with a scalpel she should jump off the table and run!

if organs were people

writing about the motherly qualities of the omentum got me thinking about the personalities of our other organs...  here is what i have so far.

heart - cheerful, super dependable, everyone's friend.  the heart is a jovial captain, often the last to abandon the sinking ship.

lungs - good ole boys, not complainers, take pride in a job well done but don't let themselves get overinflated (sorry, lame pun)

liver - a workhorse,  great multi-tasker,  can get a little touchy if overworked

gall bladder - liver's sidekick, more of a follower than a leader

pancreas -a loner, mostly keeps a low profile, occasionally throws a fit and then stews in its own juices, sometimes provoked by the gall bladder

brain - aloof, mysterious, doesn't care to share it's secrets, likes to think it's in charge of all the other organs, needs frequent rests

gut - not afraid to get down and dirty, prefers shiftwork

adrenals - frat boys of the organ world, like to kick up a little action with bursts of adrenaline

kidneys - serious overachievers (why else can we live with just one), think the heart exists to pump blood to the them, don't like to be teased for making urine


i don't know about you, but i see a little of myself in each of these organs.

not the highlight of my day either

one of the things i love about my dad is his sense of humor.  like the rest of his personality, it is gentle and humble, but also a little bit mischievous and a little bit silly.  he is retired now (from medicine, not from art), but he used his sense of humor to great advantage in his exam rooms.  here are some of my favorites.

if he was running late, he would stick his head into the exam room of the waiting patient and ask, 'did you hear about the butcher that backed into his meat grinder?  he got a little behind in his work.'

or, once, when he learned that the elderly woman he was about to examine was blind,  he told her, 'well in that case, i'm six foot two and have a full head of hair.'

but my favorite is this.  whenever a male patient would grumble about his prostate exam, my dad would gently remind him, 'well it's not the highlight of my day either!'  i love that, i think it is brilliant.  and then i try to think why.  is it the acknowledgement of the awkwardness of a rectal exam - the mix of slight discomfort and slight embarrassment?  i really don't know.  but if you find yourself on the examining end of a prostate, please give it a try.  used in the right way, a little gentle humor can put your patient right at ease.

love you dad, you're the best.

funny gynecologist

my patient saw her gynecologist.  he told her to eat right, get lots of exercise, and lose weight.  that way, he said, you can die healthy.

a touch of the holy water

for a period of time in my early twenties, i lived with my italian grandparents.  just about every night i would make my grandfather a cup of espresso.  inevitably he would call from the living room - 'and don't forget to give me a touch of the holy water!'  by that he meant anisette, the anise-flavored liqueur that he loved.  maybe that's why he could drink that espresso and promptly fall asleep.  but sometimes, you can have too much of the holy water.  and if you have too much for too long, then you have real trouble.

i will not be the first nor the last to tell you that alcohol withdrawal is a miserable unpredictable thing.  tremors, hallucinations, seizures. it is ugly and sad and deadly.  at a minimum, it is the bane of any medical resident's life.  hospitals do try to ward off disaster.  committees are formed and protocols are written.  but the sleeping beast of withdrawal is not so easily tamed.  first of all, you have no idea how much someone is actually drinking, the least likely person to give you an accurate accounting being the drinker.  so it is often impossible to predict if there is even a risk of withdrawal.  secondly, you have no idea when they stopped drinking and therefore when the fun of withdrawal will begin.  and if you try to order hourly neuro checks in anticipation of withdrawal the nurses will give you hell.  no way, they'll say.  i've got six other people to care for.  i can't do that.  so as you are writing for the substance abuse consult, you are secretly hoping you can discharge your patient in that precious window of opportunity you have between their last drink and their first seizure.  most of the time you are not so lucky.

in our training hospital we had a wing in the oldest part of the hospital called 3 west.  it was a long narrow hall with patient rooms on either side and the nursing station way down at one end.  if your patient was at the opposite end of the hall then they were a long, long way from the watchful eyes of the nursing staff.  they were also just one doorway away from the faculty offices of the internal medicine department.  i think it was my second month of internship when i admitted a seemingly normal woman to that very last bed at the end of the hall.  i can't remember why we admitted her - pneumonia?  but i do remember this.  i was sitting at the 3 west nursing station, writing notes, when my patient came staggering down the hall - barefoot and wild-eyed, gown hanging off her shoulder, ten feet of iv tubing dragging behind her on the floor.  she was reaching for things in the air (nonexistent things) and mumbling something incoherent.  she was a mess.  firmly gripping her left arm like an improbable prom date, was one of our most distinguished attendings.   he was about six foot five, white coat perfectly starched, and had a deep imposing voice.  standing over me with his eyebrows drawn together he said, 'is this your patient?'  long pause as i stared in horror.  'i think some ativan would be in order.'

i hope he was laughing on the inside.  it was the understatement of a lifetime.  seems she had crossed over, unbeknown to me or the nursing staff, into the otherworld of alcohol withdrawal and found her way out of her bed and into his office, iv pole be damned.  can you imagine?  i was too mortified to speak.  i think my grandfather had it right, just a touch of the holy water please.

spring

i love how spring sneaks up on me and surprises me every year.  today it was 75 degrees and our daffodils were blooming.  yesterday i didn't even know they had come out of the ground.  i am observant about many things, but i'm afraid nature isn't one of them.  ask my husband and he'll surely tell you.  before i met him i knew of two kinds of trees - trees with leaves (i called those trees) and trees with needles (i called those evergreens).  so when the grass starts turning green and the buds come out on the trees it seems to me to happen overnight.  like christmas.  except it's spring.

hooray!

my friend the priest

i once had the pleasure of taking care of an elderly priest.  we didn't have a lot of time together, as he was nearing the end of his days when we met.  but we had enough time to make a sort of connection with each other, more of a shared knowledge of the potential of our relationship than an actual relationship.  one thing was sadly clear, he was very alone in his retired life.  although he lived with a group of fellow retired priests, for reasons i never explored and for which he was not forthcoming, he didn't feel close to them.  i always had the sense (who knows, maybe wrongly) that he looked forward to our visits.

the first time we met, he told me he hadn't been able to hear out of his left ear for about seven years.  upon inspection, the problem was immediately apparent.  his left ear canal was completely blocked with wax.  my nurse and i got busy.  we flushed and flushed. we probed with the curette.  we flushed some more.  finally i was able to grasp a bit of the wax with a pair of forceps.  i tugged.  i tugged a little harder. finally, out came a large hard ball  (think small grape) of seven-year-old ear wax.  he could hear!  it was truly a miracle.  i asked him if he wanted to read it its last rites before we disposed of it.  actually, i didn't say that out loud.

one day he was out walking and developed a slowly worsening chest pain.  he was admitted to the hospital with an acute mi (myocardial infarction, heart attack).  he did well and was discharged back to my care.  the first time i saw him after that, i was so happy to see that he was well, that as we shook hands in greeting, and i leaned in to give him a gentle hug, i also gave him a peck on the cheek.  i don't know, blame it on the italian in me.  the look on his face was priceless.   he looked surprised for sure, but i like to think he also looked pleased.

after that he had a bout of stubborn back pain that led to his final diagnosis of cancer.  i didn't recognize it as such at first, and on a bad day, despite the fact that i know it would not have really changed the overall course of things, i feel i let him down a little in not recognizing that.  but in regards to the rest of it, i don't think i let him down at all, my friend, the priest. 

an ode to the omentum

did you know you have an omentum?  in fact, you have a greater and lesser omentum.  most of us know little of our omentum,  but none the less it serves a vital capacity in the guardianship of our abdominal organs and even our lives.

the omentum is a double fold of tissue that hangs down from our stomachs in a gentle veil to cover our intestines.  although the ancient egyptians used it to forecast good or evil omens for the survivors of the deceased, today we know it serves many remarkable purposes.  its fatty composition pads our abdominal organs, protecting them from the various intentional and unintentional assaults they must endure.  as we breath, the lower free edge of the omentum sweeps the surface of our bowels looking for and destroying rogue bacteria and other threats to our physical integrity.  if the omentum encounters the beginnings of infection, it will adhere itself to the involved area in an attempt to prevent the greater catastrophe of peritonitis (overwhelming infection of the abdominal cavity).   it has the ability to surround and revitalize an ischemic section of bowel (a section of bowel that is not getting enough blood flow to survive) by contributing its own blood flow to the jeopardized area.  Autopsies have shown various materials inadvertently left in the abdominal cavities of surgical patients to be completely encapsulated by the omentum.   it is our protector, a warrior and mother, both loving and fierce in its commitment to our survival.

once i stood across the operating table from a surgical resident, waiting for our attending to join us in what was anticipated to be a resection of a localized colon mass.  the patient was anesthetized, the OR staff scrubbed and sterile, and the instruments ready.  the attending was late. the resident, in her fifth year and fully capable of the operation in its entirety, decided to begin.  she opened the abdominal cavity.  as the edges of the incision were spread wide with the retractors, we were met with a saddening site.  there sat the omentum, heavy and caked, the color and consistency of dry clay. no glistening yellow lobes of fat, no red glow of life-sustaining blood vessels.  the resident attempted to lift the omentum to visualize  the bowel beneath.  it broke in half.  the entire OR was silent.  even i knew what a terrible omen that was.  the wound was closed, the surgery aborted.  metastatic colon cancer.  this man would die soon.

his omentum had valiantly but unsuccessfully tried to stave off disaster.  cancer had all but replaced the normal omental tissue. for many days, possibly months, his omentum had burdened itself with his disease so that he could live just a little bit longer, unaware of his fate. i had great respect for that omentum.  so please, take a moment to thank your omentum for the silent but important work it does for you everyday.

feet

when i was little my dad used to say that his feet were in the philadelphia flower show.  he would prop them up on a table and groups of ladies would crowd around to sniff them and proclaim their sweetness.  oh, if only the feet i encountered daily were so sweet.

once, after examining an older diabetic gentleman's feet, i needed to refer back to the chart for something.  the pages were sticking together.  to this day, i don't know why i did this because it is just not a habit of mine, but i licked my finger to unstick the pages.  yup.  that's right.  that's exactly what i did.

you guessed it, not so sweet.

!

i am rereading my blog and i think i use too many exclamation points.  i am diluting their power.  i will change my ways.

i promise!

the marvin principle

my favorite rotation in residency was pulmonology.  i don't really know why, what with all the phlegm it involved, but i just liked that service.  there was one man we admitted again and again for exacerbations of his severe emphysema.  his name was marvin (not his real name of course).  marvin had really bad lungs, but a really great personality.  no matter how short of breath he was, he loved to talk.

what typically happened was this.  you would get a page from your resident telling you to go down to the ER and admit marvin.  the ER knew him well, so their notes were usually pretty brief.  but you, being the diligent intern that you were, would proceed to take a detailed history from marvin.  you would spend a great deal of time asking him questions and listening to his answers.  after you'd examined him,  you would hunt down your resident to present marvin to them.

and that is the point at which you would realize that marvin had not answered even one single question you had asked, like when did his symptoms start, or did he have blood in his sputum.  you were bewildered.  he seemed to be answering you.  what had he actually said?  you had absolutely no idea.  we called it the marvin principle. the more he talked, the fewer facts you actually gathered.

when i was the resident, i never warned my interns about marvin.  the look on their faces when they tried to present marvin's story to me was just too much fun.  exactly when did his symptoms begin?  they had absolutely no idea.  marvin died of stomach cancer, but i still smile when i think of him.

my true colors revealed

well, folks, it seems that my true colors are being revealed.  when i started this blog, doctor obsessed with bathroom humor was not the image i was hoping to portray.  but (butt) ever since i wrote that hemorrhoid post, my mind has become stuck in that particular realm of our anatomy and physiology.  i wrote an as yet unpublished fart post, but i'm trying to suppress it.  (everyone knows you can only suppress a fart for so long.)  but this particular story must see the light of day.  i call it my christening.  if you are weak in constitution read no further, i promise to rise above the waistline soon.

i was a third year student on my general surgery rotation.  it really doesn't get much lower on the totem pole than that.  my intern, whom i followed around like an unloved puppy, (he himself being the unloved puppy of his resident and so on and so on) was sort of odd.  he would grab my shoulders at random times, pinning me with a crazy-eyed look, and say - knowledge is power!  well, his mantra must have served him well because he later became chief resident of surgery. i digress.  dipping into the swamp of my medical training past does that sometimes.

so we get called to the ER to see an unfortunate gentleman with a most delicate problem.  we pull aside the curtain and there stands a big burly man, bushy blond hair, red face, giant belly.  he is standing on one foot with just the toe of his other foot touching the ground and his hip on that same side jutting out at an unnatural angle.  he looks uncomfortable.  it seems that he has had some discomfort in the rectal area for several days now, just today reaching the point of complete unbearability.  you guessed it.  he has a giant angry brooding perirectal abscess.   and hence our first lesson on the most fundamental principal in the management of pus - it must be drained.

this is no ordinary perirectal abscess, no bedside I&D abscess (incision and drainage).  This particular beast must be tamed in the OR.  we need General Anesthesia (i picture a stern figure in military garb).  so we get him into the OR.  there he comes to rest, jackknifed on the table, a sterile green mountain with just a small square of space left open at the apex to reveal his backside.  we too are fully garbed - scrubs, gowns, masks and face shields.  we approach the battleground.  the intern is on one side, scalpel in hand.    i am on the other side with our attending.  the attending takes a step back.  i follow suit.  the attending takes two more steps back, mumbling something about being careful with pus under pressure.  i stick close to his side.  the intern glances up at us before pressing the blade into this poor man's backside.  looking back i think he was aiming.  a jet of tannish foul pus comes soaring out of the abscess arcing three or four feet above the patient and pouring down on me.  and our attending.  mental note to self, i will not pursue a career in general surgery.  knowledge is power.

no fun

aren't we lucky that we only lick our wounds metaphorically.

say hello to my little friend

does anyone not have a hemorrhoid?

i was going to describe the scary one i saw today but now i think it is in poor taste.

mom, if you're reading this, my apologies for offending your sensibilities.

 i'm abandoning this post...!


bad visuals!  help!



goodbye...!

i am a brilliant diagnostician! (someone tell my residency director)

sometimes i see a patient with an unusually complex set of problems or symptoms.  for whatever reason, i just can't figure out what's wrong with them, or what to do with them, or how to proceed.  sometimes i can't even figure out who to refer them to to help me - which ologist do i choose?  in those instances i think to myself - this person needs a good internist! and then i picture the general medicine professors of my clerkship years - their crisp white coats and graying hair, their confidence and their calmness and their seemingly endless knowledge - i worshipped them.  i wanted to be them.  i wanted to know everything.  they were masters of their trade and i was a stumbling apprentice.  they were not just good internists, they were great!

those clerkship years are now well behind me. and even though i don't wear a white coat, once in a very great while, i am that internist! i am the one to figure it out - to filter and synthesize and process a complex set of symptoms and draw the right conclusions.  it is a good feeling.

i received a call this morning from a neurologist to whom i had recently referred just such a patient - a very healthy female who could wake up one day feeling fine, then suddenly feel as tired and lifeless as a wet dish rag for the next four days, and then once again be fine.  she had been to doctors before, she had been hospitalized during one of her episodes, she had even seen a specialist and had numerous tests done -- all with no diagnosis (hmmm... sounds like the making of the next mystery diagnosis episode). so she went on with her life.  when the episodes struck, as distressing as they were, she just waited them out. 

when i met her, i had absolutely no idea what was wrong.  i listened to her description of her symptoms. i reviewed all the prior tests and labs she'd had done.  and to be completely honest, in my mind i even briefly thought - she seems normal but is she making this up? is she crazy?  i still had no idea.  i even had her come in during an episode so i could examine her myself.  then i did what i always do when i'm stuck - research (well, actually, when i reach an impasse like this it boils down to either research or referral, but since she'd already seen the specialist, i chose research).  i looked up what i thought were her key symptoms and came to the conclusion that she had xxx disease (now before you think she had some strange super female DNA, know that xxx is just me bleeping her real disease for privacy's sake).  making a tentative diagnosis in that way is far from being able to appropriately counsel and manage a patient with that disease, so i asked her to see a neurologist to see if he concurred with my initial impression. he did.

first of all, how nice of him to actually pick up the phone and call me.  i didn't expect that but i sure appreciated it.  and then he said two words that really made my head swell - i'm impressed.  should i  have told him that i'd never even heard of xxx disease when i met her?  that i'd googled her symptoms in my nifty online medical data base?  i said thank you.

this is one of the many reasons i love my job - my patient is happy to have a better understanding of her road ahead, i am happy to be appreciated by a colleague whom i've never even met before.  what more could i want!  my head should  return to normal size tomorrow.

doctor fantasy #1

no, not the one where i save some one's life on a plane (that's really more of a resident's fantasy, when you actually know how to save some one's life in an emergency and your head is still full of your new doctorhood.  now i just keep my nose in my book and pray that there is no emergency).  this particular one is currently my most well-developed and enduring fantasy - i call it my home for wayward widows.  yes, that's right, my fantasy is that i have a home where widows can come together and live out the remainder of their years in the comfort and fellowship of other widows.

there is of course no textbook widowhood.  and i, being relatively young and married, know very little about it.  but there are certain widows that i have in mind, a group that i encounter fairly often.  usually they are getting up in their years and typically they have been married for the greater part of their lives.   the anchor of their marriage has been pulled up and they are set utterly and totally adrift by widowhood.  however well-meaning and loving, their kids are grown and fully occupied by their own complicated lives.  their mobility has been curtailed by their bladders or their arthritis or their glaucoma.  they are at the mercy of the lonely seas.

something about the combination of their strength and fragility draws me to them.  i want to take care of them, but really i want to watch them take care of themselves.  wouldn't they have fun sitting around a big old farm table sharing laughs about their snoring farting husbands or tears about the trials of their children!  am i crazy to think i could create such a place?  is there any need?

there is a beautiful historic bed and breakfast for sale near us. when i told my friend that i wanted to buy it and create my widow home she said no!  i couldn't do that!  you see she was going to buy it and turn it in to a living history museum and inn.  well, since neither of us have a million dollars handy, we will just have to both go on with our fantasies.  that's the beauty of a fantasy - it's free!

my female-heavy schedule

on any given day, the bulk of my schedule is filled with women with maybe two or three men thrown in for variety.  i didn't do anything to make it that way.  it just is.  women often tell me they chose me because i am female.  they specifically want a female provider. i think what they really want are qualities they belive they are more likely to come by in a female.  they are using gender as a surrogate marker, much like we use LDL levels as a surrogate for cardiovascular risk.  we have to make decisions somehow.

that's okay with me.  i like women. we get along just fine.  but what i really like is to see their husbands, boyfriends or significant others show up on my schedule a few months later.  now that's a compliment!  what usually happens is this.  i meet the new patient.  as we get to know each other, they see that i am a caring doctor, they feel comfortable with me.  so they bring their partner to their next visit.  it's nothing formal but i know they are checking things out. next thing you know, they are on my schedule as a new patient!  voila!  sometimes i am the first female doctor they've had, other times not.  in the end though, gender seems to have little to do with our relationship.   i think that is the point i am trying to make -- in the end it is more about the relationship we build, then our gender.  what do you think?

ouch!

my dear patient, please do not talk when i am listening to your carotid arteries.  it really hurts my ears!

you're gonna kill me

mrs. freestyle: "you're going to kill me!"

me:  "i usually try very hard not to kill my patients"

she was really just setting me up for the confession she was about to make of how she was not taking a particular medicine exactly as i prescribed, but had come up with her own more creative dosing regimen.  hmmm.... who's going to kill you? (nah, i'm just joking, what she was doing was fine)

i get a lot of these opening statements -- you're going to holler at me -- is one i hear often.  surely they know i'm just not the hollering type.  do they want me to holler at them?   maybe i should try it, really cut loose on the next patient who didn't lose those fifteen pounds or didn't quit smoking.  i'm sure that yelling could be a very effective, or at least satisfying, way of addressing these blatant failures.  why haven't i adopted this style already?  time's a wasting - let me get yelling!