Beauty and Pain

I am in love with the NICU. The tiny, fragile patients with uncertain futures who in their vulernability are beautiful. In their beauty though there is pain, these tiny humans know pain of their larger inpatients but they have few ways to articulate it. There is pain for the ones we can’t save and for the ones we can but whose futures seem less than optimal (rather it be medical, social, etc). But there is such unparaelled joy in the ones we can save, the ones who grow and develop as they should.

This weekend my spinster Aunt got married at 47 to a widower with 4 kids. It was a beauitful ceremony filled with the excitment and joy surrounding any wedding. But there was saddness too, sadness for a mother who died before seeing her children grow up.

I hurt my knee at the wedding. I didn’t do anything but I woke Sunday morning with a hot, swollen knee that felt like I had torn something to bits. Last week I dislocated my elbow… I’m a  bit of a rheumatological mess right now. I’m in love with my work, the babies and peds in general but i am in constant pain. Its been a long winter.  I do believe that the hip’s death spiral is putting undue pressure on everything else.  I have resigned myself to surgery in March of 2010. I am dreading it, the idea of going back to the place I lf behind a decade ago is scary.  but I am grateful for it.  That there is a light at the end of the tunnel! Its a beautiful thing.

and the truth is I want to get on with my life, with doctoring babies and dancing at weddings and loving it.  thats a beautiful reason to be willing to take the risk of surgery.

Important Things I learned in Medical School

We need to liberate the Iraqis in the duodenum

Its all comes back to bacon and a kid named Tony.

Cardiology is better with an adult beverage in your hand.

All the colorful language I use I learned from Dr. Chatterjee.

GI Joel is the coolest block director ever.

If you eat Polar Bear Liver you will kill your own liver

Reindeer do not have gallbladders

Do not eat your hair.  It will cause a massive obstruction in your GI tract over time.

Vulvanman and godzilla are friends.

That’s the straight poop. (Its all true)

Don’t play with guns.

Don’t play with bricks.

Don’t play with hot water.

Don’t play with knives.

Don’t play with nails.

Don’t play with toothbrushes.

Don’t eat Mr. Potato Head parts.

Don’t play with cars.

Don’t play with lawn mowers. Actually lawn mowers should just be burned.

One nut is better than no nuts.

Never underestimate the high frequency of less than one in a million.

Med students are man’s simplest tool the wedge. Its always our fault.

Anything smaller than a a baseball can be stuffed into nearly any body orifice.

Delivering babies is not a sterile procedure.

The uterus might be the most amazing organ of all time.

My parents’ home is NOT a substance abuse facility.

Its easier to apply for disability with many diseases than it is to find a job with insurance that will cover said disease.

One should never see cats in the ICU but one may occasionally actually be right about being paranoid that the FBI is tracking you.

Electroconvulsive  therapy is shockingly anti-climatic

In the end it all comes down to fluid.

how you die matters.

bagels taste better at 2AM.

I am on pg 417 of Smith’s book.

Informed  consent is a relative term.

Cancer sucks.

It looks like a rt bundle branch block…it is a rt bundle branch block.

When it doubt it congestive heart failure. When its not CHF, its probably HIV and if its not HIV its probably TB.

Messed up kids have super messed up parents.

Everyone is addicted to something…the question is how quickly will it kill you.

You can actually exnucleate your eye with your own hands.

Never underestimate what can happen with anyone with eyeballs in a mile radius of small, sharp,pointy objects.

Cameras in the workplace just scare the crap out of everyone.

All bleeding stops.

Adults need something to do in the hospital other than stare at the walls and ponder their fate.

SKIP BO is an excellent example of a better activity.

Losing the ability to walk. Difficult. Losing one’s ability to feed one self. Difficult. Losing one’s ability to commuinicate Difficult. Losing the ability to think, relate to the world.  pricelessly horrible.

Protected: and most of all for the children who are perpetually caught in the mist of the follies of politics, the good intentions, quick judgments of the west, a craving for melodrama and a severe lack of resources not the least of which is love.

the state of the elf.

I spent a good portion of my afternoon playing

Skip BO

yep. I played cards in the middle of the neurology nusrsing station for two hours. The patient (Ms Smith) has severe MS that effects her/his mental capabilities.  Ms Smith also is stubborn and nearly impossible to place in a nursing facility because he/she is so difficult!! Ms Smith  has been in the hopsital three times during my neuro month.  Ms Smith  is more with it than we all her give credit for, mostly she is ticked at her lot in life.  She remembered me from two weeks ago, remembered I sometimes am on wheels.  On her little bio that her/his family filled out they said she/he likes SKIP BO. Well I happen to know where they keep Skip BO in the child life room so I took a little unauthroized field trip and brought it back to the adult side. And she taught me how to play. She was so grateful and did not require any sedative and took her meds.  The Chairman of the neuro dept is on service this week and saw what I was doing and was impressed.  I blushed, told I her I wanted to do peds and said thanks.

What I should have said was this was as much thearpy for me as it was for my patient. Skip BO is about order, numbers, you make orderly piles of 1 through 12. Everything has a place, a match, an anaswer. Skip BO is the oppositte of my life. I can control Skip BO so can my patient. Maybe thats why she loves Skip BO because she can understand it and control it . How do you understand your immune system eating your brain, your memories, your emotions, your relationships?  How do you understand not being able to be cared for at your own home, not being able to feed yourself at times and not signging your own consent forms…. How do you accept not having control of your own body, your own life, your own fate?   You don’t ever really accept that. You don’t ever really get used to the idea or understand it.

In reality so much of mine own fears are caught up in control issues. I like playing doctor because I am on top, I am in control I can make decisions. I dislike being the patient for the opp of all of that. I dislike the match process because in the end I trust my fate to a computer system and God. Spiritually I struggle to really trust God, to surrender control.My problems are small in comparison to my patient but I think maybe I understand her just a little.

So I play Skip BO with my patient and we both feel better and we both feel less likely to bite the next person who annoys us or reminds us what we have looming over us.

The Four Moods

Doctors have four moods curious, annoyed/tired, sad and confident/excited. We are curious as we gather information about new patients or problems. Sometimes we are sad because there is nothing we can do for our patients so we are sad with them. Sometimes we are exhausted by our patients or annoyed because they just don’t understand that either we can’t help them because they won’t help themselves or we simply not the right sort of doc for the job. Lastly there is the confident excited mood. This is how we feel when a patient with a problem comes to us and we either figure IT out or better yet we can help them, make them better.

I traveled 14 hours round trip to play patient today. I squirmed there on the stool waiting with mother and sister for the verdict. As I habitually have since childhood I had dressed nice today, combed my hair back. I sat there and tried to read neurology and supress my curiousity of the open doors with other waiting patients and keep myself from fidgeting from anticpation and the constant gnawing of my left hip. The fellow came in and took the history. As I recited the truth about the hip pain the little student doctor in my head knew exactly what was a red flag hearlding surgery. I interviewed myself I gave a concise chief complaint, history of present illness, what makes it better vs. worse, what I had tried, my past medical history, etc. He leveled with me on the x-rays. I had already seem them I knew and before I knew I found myself explaining with him to my Mom how bad it was. The language flowing off my tounge: narrowed joint space, osteophytes….

The attending came in and he was completely different than the first time I had met him 4-5 yrs ago in which he spent four mins with me in haste made a comment about getting a baseline. This time he looked right at me with that look. The fourth mood the one where a doctor sees a sick person and knows Ahha this is somoene I can make well. For some reason this unnerved me completley and made me feel disoriented . He shook hands all around as I scrambled up from the stool to the exam table giving him a sit. He looked at me and said how is life. It was a loaded question. I talked about med school and pediatrics and we tangentially talked about the step 2 board study book I was clinging to as if somehow would keep me afloat, then I cut to the chase and recited the history with its red flags.

He sat down and said it sounds like if you lived closer and I seen you more often we would have already done this. We talked about doing a regular hip vs. resurfacing (not a good option with my bone consistency (jello)). And before I knew it we were there and I was a bit tachycardic because I was 24 and looking at a hip replacement and even though I had driven 7 hours for this I somehow found myself fumbling and unprepared. A million things were happening all at once… I started having surgery rotation flash backs and flash backs from childhood and had a million questions and didn’t know how to process it all. It just tumbled out, if I have such low bone consistency doesn’t that put me at risk for shorter lifespan of a hip prosthesis. He gave me THE LOOK and said his goal was 20-30 yrs and as he was sure I would tell my patients think of this as a postive, some that is going to change your life for the better not ruin it. He took out a pin and gave me his home phone number to call at my convience when he could answer all of my million questions with out the constrains of clinic.

I was shocked, he was breaking one of the cardinal rules of medicine. Maybe it was because I was baby doctor (a student doctor and a doctor who doctors babies J )or maybe because he saw the look of skepticism in my eyes or maybe he does this for everyone (doubtful) or mabye it all went back to the fourth mood. It was his way of telling me what to do but in a professional way that didn’t’ tell me what to do . He offered me a steriod shot, told me that he didn’t trust anyone but himself in doing it and that I should try it especially if I really wanted to wait 10 months till after the match. He said he could do it NOW and I thought what the heck at this point I am carrying around a half dead hip.

So I am whisked into the treatment room, left alone and strip my pants off and lay on the fluro table with a gown over my body. I stare at the celliling for a while and focus on breathing. The tech and the doctor come in and what was a 35 min procedure at Wake was done in 45 seconds.I told him that the doc at Wake had said I had strange anatomy and he proceeded to tell me to tell my attending there that he was wrong my anatomy was not that odd at all, he made several jokes at his expense until he noticed me watching his every move intnetly and told me to look away because it would make me nervous. I explained I was sick and twisted and like to see what was coming at me. He cleaned the area and completely left out the lidocaine and the contrast and thrusted a large bore syringe into my joint space. I sat up and he shook my hand again told me I could come back in three mons for another shot and that I should call him.

And then I am driving back the insane drive through mountains and ponder that fourth mood is about trust buliding. Its what allows our patients to trust us with scapels and needles and poisions. It works better when our patients don’t know what coming and when they don’t really know what they are signing up for. But you see once you know the technique, the tatic, once you know that behind the curtain is not a wizard but a man, its hard to believe. Its hard to say yes give me respiratory depressing poisions, take out my femoral head, replace with some forgien body that you say is going to positively change my life that I say is an infection, a femur fracture and a huge risk to my walking life in the making.

There is no choice really, the surgery means Africa and hiking and roudns without pain and internship year and walking at graduation without cringing.

But I am still skeptical.

Igoranace is bliss. Knowledge makes simple decisions fraut with reality.