Morphine and Hand-Holding… When the word “fix” changes meaning.

Sometimes, we, as humans, are helpless.  Subject to the needs of our biological bodies and in a position where we are doing well simply to breathe.

Babies, despite being tough little cookies are helpless.

And sometimes, when we are critically ill or dying, the same phenomenon can take place.

Life comes and life goes.  That is how we were made.  Our Earthly bodies are finite.

We celebrate birth, but fear death.

Birth and death are not two different states, but they are different aspects of the same state. There is as little reason to deplore the one as there is to be pleased over the other. –Mahatma Gandhi

I have been covering call for the internal medicine floors.

I love internal medicine.  You can help a ton of really sick people with complicated disease get better.  The thing is, lots of sick, complicated people don’t get better.  At least not in the sense that most doctors or other people, for that matter, want to see.

I got called a couple times overnight to see someone.  A new admission.  Who had recently been admitted, but got better and went home.  And was now sick again.  Sicker.  This person had decided after past experiences to refuse intubation or other breathing assistance aside from oxygen.  So, we were treating the underlying disease and hoping for the best.  Otherwise this person would be in ICU on a ventilator.

I went to see this person, curled up and looking tiny in the big hospital bed.  Just breathing.  Breathing with every muscle in their body despite the high percentage of oxygen mask on their face.

I politely ask how the person is doing.  I knew the answer.  It was written all over their tired face.  They couldn’t breathe.  And as the med student behind me said later, we really weren’t doing much about it.  Some oxygen, some steroids, puffers and antibiotics and crossing our fingers.

I don’t know if you have ever not been able to breathe.

I have.

It is a terrible feeling.

So, I can only imagine how terrifying it would be knowing that you may very likely die from this distress.

We listened to her lungs.  Held her hand.  Asked if there was anyone we could call.  The answer was no.

I went back and looked at the orders.

Nothing for anxiety.  Nothing for pain or to ease the struggle with the breathing.  The plan was ICU until very recently.  And other issues until the situation became more grave made the use of anxiolytics and narcotics not the best idea.  But now, as the nurses said, they basically sent her to the floor to die or get better, whichever came first.

On-call residents are not supposed to change the management too much.

But really, sending me a possibly dying patient without palliative orders is unfair.

Not using invasive measures to sustain life does not equate giving up.  It just means that we don’t violate the pulp out of a person for what may be a non-existent benefit.  However, people who do not have CPR or ventilation often still receive other treatments to help their underlying problem by treating infections, diseases or symptoms.

Sometimes we withdraw everything except for comfort measures. But this decision comes with even further discussion with the patient and family and looking at other things in the picture like the stage of the disease and the goals.

At this point, this person was having their disease treated.  They still had a small but reasonable probability of recovery with treatment of the underlying problem, although their chances of coming off of a ventilator were slim.  We were also managing some symptoms, but they were still having significant difficulty.

I wrote an order for Ativan and for Morphine.   I had a good chat with the student about providing comfort care regardless of the prognosis, but especially when people are end-stage.  I showed her how the blood gases showed the patient was tiring out and medically needs intubation.

I looked in on the patient before heading to bed.  Still curled up and puffing away, but asleep.  I whispered a prayer and went to bed.

I was called to that floor a few more times over night.  Never for that person.  But, a few others with more “fixable” problems.  Things that feel miserable like shortness of breath and nausea, but that are often managed easily with some reassurance that the medications we ordered with soon kick in and they will likely feel better.

There is something satisfying about the easy fix problems.  Knowing that they likely will get better.  Knowing the next step if they don’t.  Or that someone else probably does.

Plus, easy fix problems are ones that can be resolved quickly or at least easily and thus we all get more sleep.

Even in people who are at a point where their problem cannot fix, there are easy fixes.  Sometimes, a simple change can resolve the unpleasant symptom, like the feelings of smothering.  Or holding IV fluid overnight in someone who is beginning to go into heart failure because their kidneys have now stopped working.

There is also something satisfying about seeing someone sleep after a night of feeling like they were dying, even if you likely didn’t change anything big.  At least you gave them some peace while you wait to see if the other solutions will work.

But, there are things that aren’t easy fixes.

There are the obvious difficult situations like complex critical illness, people who are so sick you can’t leave their side, those that need monitoring and multiple medications.

Even once people are beyond those things, there are still tough fixes.  Like fear.  Or loneliness.  Or the knowledge that death is imminent and you are scared.

Sometimes staying awake after a simple call and holding someone’s hand while they breathe and sleep is more satisfying than reviewing the second chest pain (that almost always is nothing) of the night.

The patient was still alive when I went home.  Still looking terrible, but less anxious and ever so slightly better on paper.

Things are complicated.  People surprise you.  People you expect to die live and vice versa.

We are all human.  We all deserve good care.  Even if it is the end of life.  We put tons of money and time into babies (and we should).  But, why not our elderly too?

I love internal medicine.

We get to fix people.  Even if it isn’t always in the way we conventionally use the word “fix.”

Some people you just want to kick in the teeth

Last night/this morning, I finished my last general surgery call shift.

I classify it as a win in my books.  I survived.  And, to quote Patrick’s grandmother, “I didn’t know if I would ever make it.”

This was probably one of my better calls.  Aside from me forgetting my phone at home in the morning and trying to stalk down Patrick to get it back (iPhone=brain). It was the best call for sleep for sure.  I got a few decent chunks of sleep time. I had a few sick patients, but they were all stable by midnight or so.  It was steady all day up to that point, but from then on, just the odd call and assessment.

The nurses at the hospital I work at are really good.  The majority have been around for awhile.  They have good common sense.  They care about the patients.  They help me out a ton. In fact, I think I learned as much from the nurses while working the floors as I did the other residents and attendings.  Because the nurses are so awesome, there are minimal really silly calls for trivial issues.  I am so grateful for them and the work they do.

The thing is, there are some things that you always have to call someone about.  Because it is safer to do so than to not do so.  Things that are life threatening… You know, chest pain, fevers, new shortness of breath, excessive vomiting, etc.

This is where I got bitter last night.  And similar events have happened in the past.

I got called.  Out of a dead sleep at 3am to go see a patient with chest pain.  Perfectly reasonable.  I was already on my way out of bed as I heard the words.

I ordered the routine bloodwork and ECG and headed to the floor.

There, I was greeted by two of the staff who explained to me the patient is on high dose narcotics at home, is angry because we aren’t giving them more and when they were told this promptly started to complain of chest pain.

Suspicious.

But still, you just never know.  Bad stuff happens.

So, I go in to see the person.  They look comfy.  They don’t look sick.  Their vital signs were better than mine.

They give a story of having chest pain for the entire day and night.  It got worse a few hours ago.  The nurses are withholding pain medications.  Now, the person can’t move that side because the pain is so bad (as they move said side to demonstrate).  And the story kept changing.  And was inconsistent with most pain, except maybe post-op pain, but even that was a bit dicey.

Their ECG was normal.  Their bloodwork was normal.

So, I had the whole, it doesn’t look like anything life threatening talk with them.  And they asked for more pain medication in addition to the additional stuff that I just gave them.  I questioned this, as they had just said the pain was subsiding.  To this they said they could feel that it would come back.  I said to let the staff know if it did.

I am all about helping people.  And good pain control.  And giving people the benefit of the doubt.  But nothing makes me want to punch a person in the face more than when they are clearly trying to manipulate me and they do it in the middle of the night with a complaint that could be really serious.

I had someone else a few weeks ago who was being super rude to all of the nurses and roommates and started complaining about coughing up blood in the middle of the night.  Same sort of deal.  They did cough up a bit of blood.  The also had a nosebleed earlier in the day from pulling out their NG tube earlier in the day.  But, they did that earlier, but chose to point it out in the middle of the night when they were starting to be ignored.  I ended up getting stuck there for an hour debating the reasons why medications are sometimes given late and why we won’t give him more benzos and the like.  Really nothing to do about the mysterious blood.

I had someone else who every time we have tried to send them home, they present with a new problem that precludes discharge.  Pain, a new rash, dizzy spells.  They are genuinely sick.  But they also lean towards the dramatic.  It gets frustrating.  I just want to see them get well and go home.  Partly because it gets tiring for us getting called to assess and making arrangements just to have them changed.  But also because sometimes the best thing for people is to not be in the hospital.

I probably sound heartless.  I love people.  I love my job.  I enjoy taking care of people.  But, nothing is more annoying than people who take advantage of the system or who manipulate you.  Especially in the middle of the night.  When other people are actually sick (or you are trying to sleep).

Some people have genuine issues both with their mental or physical health and can come off as manipulative.  I take them seriously.  I investigate appropriately.   Except sometimes it is hard because they don’t give you much to go on.  Or it is clear that things aren’t as they say.   Then, I kind of secretly want to punch them in the face.  Especially when I am in the midst of getting pages about people with more pressing issues.  Or when nursing staff are being taken away from sicker people.  Or when we are all being abused.

There is an element of common sense here.  Some people don’t seem to have it.  And I suck at being a jerk.  So, often I still get caught up with these people until I get so annoyed or confirmed that they are being manipulative or drug seeking to talk them down.  I am getting better at judging this and approaching it.  I just don’t like to be mean.  So, I try to educate.  It takes longer.  It works most of the time.  It doesn’t mean I still don’t want to kick some people in the teeth.

I guess such is life.  There are always those people you want to kick in the teeth.  And it is most often at a time when you don’t have the time to deal with it.  It amazes me how self centered we as people (on both sides) can be… Me for wanting sleep or to deal with people with problems I need to fix and them for, well seeking attention for problems that, at least from the outside, can seem trivial (though for the person they can be significant).

But, yay!  I survived Gen Surg call.  And I didn’t kill anyone… Literally or figuratively.

Hospital

Hospitals are interesting places.  They are like small cities that never sleep.

Often, people regard hospitals with fear.  They think of them as cold, quiet, unyielding places filled with terrible sounds, terrible disease and terrible people.

In reality, I think the perception is sometimes correct.  There are rare times when all of that is true.  There are more frequent times when some of it is true.

I am comfortable in hospitals.  I have worked in them for years.   I see a subtle beauty and intricacy in them.

During the weekdays, hospitals are bustling with activity.  Everything is opening.  People move around freely.  Like organized chaos.  Voices are at normal volume, changes happen all the time.  At this time, hospitals are most familiar to people.  This is the time most people are in the hospital.

Day hospital is so busy, so big, you miss people.  You talk to all sorts.  You do plenty of work.  It seems time is more limited.  You have to rush from place to place.  There are labs to check and many people to see and clinics and ORs to attend to.

A strange thing happens around 5 or 6 o’clock. Things get more quiet.  There are less people.  Fewer noises.  Not everything is open or available.   Evenings in the hospital are a time of visiting, of relative stability.  Less change happens in the evenings.  Only important things.   Family is present.   Chaos dwindles.  Just like on the weekends.

As the night grows dimmer, the hospital becomes dark.  The lights never go out completely.  It seems things, in some ways, don’t change.  Through the darkness of patient rooms, nurses and doctors creep in and out checking lines, giving medications.  Only the sickest of the sick travel the halls for urgent tests.  Things close down.

I love the stillness of night hospital.  It is a wonderful time.  Night hospital is one of the times where hospital life resembles that of a big city that never sleeps.  Still the majority rest, but the ones that work, hustle and bustle with the fervor of someone in the day.  It is peaceful, it runs like clockwork.  The fewest changes, the least chaos is at night.

You can walk the halls and hear the sound of your own feet.  People are more friendly at night, probably because they are fewer of you.  The night gives you a commonality.  The night gives you time to appreciate people more.

Night hospital makes me uncomfortable.  I love the peace, but I am used to day hospital.  I am familiar with the chaos, with the need to get a million things done.  I can deal with the pages and the running around.  There are other people around.  At night, you are more alone.  You feel vulnerable.  Any problem or complication could become more significant than in the day.  That is how people learn.

Night hospital is also eerie.  It can be lonely.  It can be scary.  And it can change very quickly.  Things go wrong day or night.  That is why the hospital is always staffed.  There is nothing worse than the peace being broken by the beeps of pagers, the buzzing of alarms and the sound of a code.  No, wait… There is… The cries of loved ones.

Hospitals are ecosystems.  There is a balance.  There is a sort of day/night dichotomy.  People depend on one another.  They grow and they change.  Yet, the patterns and relationships somehow feel similar regardless of where you are.  Like a symphony played by different orchestras.  Sometimes there are different mistakes, different flourishes, but overall a similar feel bound together by the things that make it similar – the notes on the page or the patients in the beds.

Don’t Shoot The Messenger

As the junior resident on my surgical team, I am often the bearer of everything related to the inpatient floors, which includes much bad news and a number of messages that are not taken to kindly.

I do what I can to manage things on my own, but often times, I get sent on little missions (or big missions) from the staff or seniors to ask for scans, sort out orders and do all sorts of other things.  That is my job.  That is how I learn about how to manage the more complicated things.

Sometimes, though I get sent to ask for things that are a touch on the outlandish side.  Or difficult to do.  Or just plain disliked.  And then I am the one who gets to hear and bear the brunt of the reaction.

Take today, for instance.  I was told to go order a CT scan for my septic post-op patient with a known history of Crohn’s.  Seems simple enough.  Problem was, this patient already had 2 CTs in the last month (and one was only a few days ago).  The team agreed it was a tough call, but we just had to be sure there was nothing there we needed to drain or operate on.  I, of course, got to go to radiology to ask for the scan.  And of course, they didn’t want to do it.  Because the interval was so short.  And the indications, though good, were limited, as the patient has had so many prior surgeries and had identified potential sources of infection on the last scan (fistulae and such from underlying disease).  I got a lecture explaining radiation risks, and resources and the effective use of scans.  I know these things.  But, I was stuck.  I already had questioned it.  And it didn’t work out.  In the end, I had to get my senior to talk to radiology.  The scan did get done.  It didn’t show anything.

In another instance, I was told that another unstable patient did not need to be transferred to intensive care unless vitals did x, y and z.  I did agree with this, it only made sense.  They were stable, but happened to have a giant clot in an extremity and a tiny one in a lung.  I had the misfortune of reporting this to the unit staff.  They are extremely experienced and very helpful 9 times out of 10.  But this time, they were extremely busy and pushing for me to get the patient transferred.  I couldn’t do that.  It wasn’t my place.  And it wasn’t necessary.  I heard the brunt of the complaints.  And I heard them discussing it (and me) in the next room.

Then, there are the really not warranted reactions (at least not on the grounds of my action alone).  The people who flip out at me for coming to assess them on morning rounds, for instance.  Or the resident that gets angry when they get paged for a reasonable consult.

Yes, there may be other things going on to cause their reactions.  But that still doesn’t make it a completely acceptable way to respond to others.

I understand that the natural human reaction in upsetting circumstances is to vent or get angry.  And I understand that I am still learning and sometimes do some REALLY stupid things (take when I cancelled and reordered different doses of the same med three times between discussions with the team and then pharmacy and then nursing).  I get frustrated with me too.  And that is a way of learning.

But sometimes, I have to do things, not because I want to or even because I think it is best, but because it is what I am being required to do (whether it be for medical/legal or team hierarchy reasons).  I appreciate the learning opportunities and hearing opinions, but there is no good reason to shoot the messenger.  Even if she is the easiest target and the one who appears most at fault.

These experiences will help me as things move on.  I will remember and maybe make different choices.  And maybe stand up for what I know and believe to be right or true a bit more.  But also, I will try to not create situations in which other people will want to shoot the messenger unnecessarily.  And maybe I will not shoot the messenger so much myself.  Because some of these behaviors are a cycle, not just learning or human frustration.  By stopping the cycle, maybe I will save someone the angst of being talked to for things they can’t change.

Sometimes, people have good reasons for doing things you see as wrong or stupid.  Your reaction may be warranted.  In fact, in my first two examples, the reactions were, at least somewhat warranted.   There were things that could have been changed to make things make more sense and the actions may not have been the best.  I get that.  Sometimes, you have to tell someone and get upset.

But, sometimes, more thought needs to go into who and why things are happening.  And who or why to be angry.

I guess it all comes down to not shooting the messenger.  Unless, of course, they are the source of the message that could otherwise be improved.

Mail It In: To the surgery team (Daily Post Challenge)

This week’s writing challenge with the Daily Post aligns perfectly with something I had intended on writing about anyway.   Except instead of just writing, they suggest I do it in email form.  

Hello Surgical Team in a hospital far, far away,

How are you today?  Good, I hope, despite some of the rain we have been getting lately.  I guess it is better than they humidity you have been having all summer. Things here have been hectic as usual, but I kind of like it that way.

I just wanted to let you know we saw Mrs. X here last week.  It is pretty crazy how she somehow was so well and out and about as if nothing was wrong just a month ago except a cough chalked up to allergies and then was in hospital in respiratory distress.  I am sure you were just as shocked as I was to see the giant mass blocking air entry into her left lung.  Well, I guess based on the clinical picture, it wasn’t quite as shocking.

Needless to say, based on what you were saying the weekend before, she would probably die over the weekend, so we held off bringing her down.  I mean, obviously surgery can’t fix it and radiation is the best option, but you can’t have someone die on an ambulance ride to get palliative treatment.  That just isn’t right.  But, she stabilized and survived the weekend.

In fact, when I was paged to go see her, I still expected to see someone frail and unwell.  But, instead I found Mrs X.  On 15L of oxygen, but sitting up in no distress reading a novel.  You didn’t mention how sassy she is.  My attending was off seeing another consult, so I started taking her history and was floored at how well she was and how sick she got.  I also quickly realized that although they knew surgery wasn’t an option, she and her son were oblivious to how bad thigs were.  There was no cure.  In fact, this lady was dying.  Maybe not as quickly as we thought last week, but quicker than you and I.  And she had no clue.  None.  All she knew is it was a lung cancer causing the trouble.  And they had to drain the fluid from around her lung.  Not that she had no air to her lung, that the tumor was invading a main vessel and the heart lining  not that she had big mediastinal and hilar nodes and a 2cm lesion in the opposite lung.  She just new she was coming for a “shot of radiation to help fix [her] breathing.”

We did the radiation plan.  A single fraction and then she was to return home.  After planning, she became acutely distressed and we had to give her morphine to settle her.

We sat down and talked with she and her son.  They hadn’t heard the cancer spread.  That having this kind of fluid on the lung is a bad sign.  That the tumor is so big and so extensive we can’t treat it all and, actually, we don’t even know if the radiation will make a sigificant difference.

Amongst themselves, they had still been talking cure.  Or at least a few years.  Her other children live far away and she had assured them not to worry, not to come home.

We were looked at as if we had ten heads talking about symptom management.  They knew we were just for the breathing, but they still hoped something else was being done.  She wanted to go home soon.  And here we were explaining that things weren’t good.  That home may be difficult with the high oxygen need and talking about getting palliative care involved.  About doing things sooner  rather than later.  About having her kids come home.

They appreciated the honesty.  They understood what we were saying.

It felt terrible being the bearer of bad news.  Not that we don’t do that every day, but because they were at your hospital for days and oblivious.

I know sometimes people don’t hear what you are saying.  You can tell them bad news or good news and they just hear what they want to hear.  People get overwhelmed with things.  So, maybe you did tell them and they didn’t understand.

I also know we, as physicians, get overwhelmed.  You forget to go back.  Or you are scared to go in and say things like palliative and no cure and such.  Especially when you are so busy and you don’t deal with this stuff as often.  I know,  It would be easier if you could have just cut it out or referred her on.  I have sometimes let things go because I was scared, especially when I am unsure of details.  And sometimes, people are vague or they seem to get it, but they don’t.  Those people are easy to gloss over.  Easy to brush off in your mind, perhaps.  But, sometimes, they need even more attention.  I am not perfect.  I screw these talks up.  I am just starting out and I screw up all kinds of things.  But, I think it is better to try and to care and want to help.  Talking to people about death and dying is scary.   But, that isn’t fair to the patients or the family or the other staff to avoid the topic or to not address it appropriately.

I am not speaking on a stereotype here. I am not trying to type you just because it happened.   People often think surgeons are cold and harsh.  But anyone can be cold and harsh.  I am saying this because not everyone is and no one has to be.  Stereotypes are just stereotypes.  People can get beyond them.  In fact, I think you have gone beyond them before.  You talk to people about tough stuff all the time and care very much.

I think you have  done a lot for these people, even if it wasn’t cutting the tumor out.  It just bothers me that, in a way, they were left on their own because it couldn’t be cut out.

I also know some of the team member’s hands were tied.  You can’t say anything until someone ahead of you does.  I have been there.  There is a chain of events.  I know how distressing it is and what a moral-ethical battle it is.  Thank you for being there for these people. I hope this makes you think about your decision as much as it has made me think about mine in the past.  I hope you know you are doing the best you can.

I am glad we got to help this family.  I like seeing people be aware of the things to come, know what they should be doing and understanding what is happening right now.  I am sad that they had to hear this kind of news from physicians they just met.  I am upset that you didn’t give me a heads up about how much they didn’t know or what you chose not to cover.  And, selfishly, I am mad that the lack of information you left them with caused multiple hiccups in my day and in the way I was perceived.

These things happen.  We all have off days and strange encounters.  I know it is not your habit to have these sorts of things happen, but I all the same, it is not the first time I have seen people in similar predicaments.  Communication is so important, especially in these life threatening situations.  This lady could have died and it would have shocked everyone more than it necessarily would have to.  We need to make time for people and for these tough situations.  Even though it is scary.

Sorry to be so harsh.  It is just that I really have a heart for people in these situations.  I want to help the dying live.  But, I believe honesty is so important and I feel that they could have been signficantly hurt by the approach that was taken.

On a brighter side, Mrs. X had a good laugh when we had to take her picture for the ID for treatment.  She was unimpressed, as she didn’t put on make up and thought we were only going to take pictures of her chest.  She also said she is very grateful for all of your help, as she is much better than she was when she came in to hospital.

You are great at what you do, but just don’t forget the people you care for.

Say hi to Mrs. X for me.  Take good care of her.  Keep me updated.

Take care!

Trisha

This is what I wish I could say to the surgical team who does a lovely job at what they do, but turfed us with a very sick and oblivious patient and family a few weeks ago.  The good thing is, scenarios this bad don’t happen that often.  The bad thing is that they still happen.  

**The details of this case were obviously changed to protect the privacy of both the patient and the team caring for them.

Would You Rather?

Classic Would You Rather questions. Image from learnercentered.wordpress.com.

Remember the game “Would You Rather?”  The one where you give someone a choice between two seemingly equal awful or awesome options and see what they pick?

Patrick and I used to play it when we were dating.  Generally on our Facebook walls.  I am sure it was super annoying to our friends who kept getting our updates on their feeds.

We also played it a great deal at campfires around that time period.  One of our friends, K, had a favourite, somewhat inappropriate question that went like this… “Would you rather pee yourself and everyone know or poop yourself an nobody know?”  Every time.  Regardless of audience.  Actually, she resurrected the question over barbeque at the trailer last weekend.  Because she is good like that.

The catch with “Would You Rather” is that you can’t really ask clarification questions.  You need to take things at face value.  Without subtext.  At least that is how we play it.

At work, I have run into a “Would You Rather” type scenario at work.

Okay, really, much of medicine turns into a big game of “Would You Rather.”  Choosing between treatments is kind of like choosing between two evils.  Except you get informed of subtext (like side effects and cost) up front… At least theoretically.

For instance, some people with low-intermediate risk prostate cancer can choose between surveillance, surgery, external beam radiation with or without hormones in conjunction with a clinical trial or brachytherapy (radioactive seeds in the prostate).  A lot of choices to make.  Many factors to weigh.  Lots of subtext.

I find the way people make decisions interesting.  Some decide instantly, others debate for weeks or months.  Some people have things they are terrified of (like having surgery or foreign bodies in them) and that simplifies things.  There is no real wrong answer (well, some people aren’t eligible for certain options by merit of the size of their prostate or subtle disease features, to they may not have certain options offered).

Unlike the game, the decision has life long consequences and can influence quality of life and other things for years to come.

But, there are shorter term decisions too…

The men who are receiving hormones take these injections every three months to help suppress testosterone.  They are given by a doctor (like me) in a lovely preloaded syringe in the fat on the belly.  And the needles is big.

Some doctors I work with (interestingly, the men) give a dose of lidocaine just underneath the skin to help numb it before giving the big needles.  Others (mostly women), just give the needle.

The process when giving just the needle is faster and, honestly, I haven’t had anyone freak out or pass out or anything.  The lidocaine involves a second injection, and the injection of anesthetic stings and takes longer than just the one poke.

Where I have worked with people who have done it both ways, I have done it both ways.  I generally prefer to just give the needle.  Because it is faster and easier.  I don’t think I am cruel, but really, why go through the two pokes and the sting of the lidocaine?

Towards the end of this week, I was told to do whichever I preferred, so I started asking the men for their preference.  I was currently working with a pro-lidocaine doc.  The men were baffled by the choice.    To me, it seemed simple… One needle or two?  Quicker or slower?

Most of the men were hesitant to have the needle without the lidocaine, including those who hadn’t had it before.  They were scared of the pain from the big needle.  One opted to go without the lidocaine and was surprised that it was easier for him than getting both needles.  He asked why people would bother with the two pokes when they could just get it over with.  That was my thought too.

Like a game of “would you rather,” the choice between the injection or the anesthetic and injection is one with two undesirable options, however, there is some obvious subtext to it.  For me, the choice is simple both as a patient and as a practitioner.  But, everyone can make their own choice.  Especially when each is not desirable.

But, for future reference… One needles is always better than two in my books.  Despite me not being afraid of needles and regardless of the size of the bore.

Distance learning

I had my first real academic half day today.  And by distance to boot.

It was kind of like the first day of school.  Except I don’t get cool new supplies or anything.  Just a teleconferencing access code and a room to sit in.

I have been in courses previously that were video conferenced to other sites and I didn’t enjoy it then because the technical issues were always delaying things and then we had a prof who liked to make us do group work through the computer screen.   Plus, there is something awkward about being in one of the seats captured by the camera, so that you always seem to be in view.

In fact, today, we attended lunch time rounds with another site via video conference.  The camera in our room was malpositioned, so only the tops of our heads could be seen.  No complaints from us.  Until, miraculously part way through the presentation this message appeared from the videoconference Gods or something telling us to fix our camera because the other participants can’t see us… Obviously.   It kept popping up until we fixed it.  And our lovely, lunch eating faces were on the screen.

I spent all of my family medicine rotation doing half day by distance (because we were all distributed to all kinds of random small towns) and it was an online conference with no video.  And it was in the morning.  And I did it from home.  The beauty of this was that people could not see you.  And they couldn’t hear you unless you wanted them to.

As a result, I attended these sessions in pajamas, eating breakfast, having Patrick wander by in a towel,  amongst other things.  You could do anything really.  The professionalism police could kill me for some of it.  If they saw me.

Today, I attended the session from a conference room in the hospital.  By myself.  In a spinny chair.  I spun, and chewed my pen and ate a snack.  It was as delightful as being alone in a room can be.

The problem was that I was supposed to be learning.  It is very difficult to focus on a lecture when you are not in the room and can’t see the lecturer.  Plus, I have learned this material before in my undergrad.  And the lecturer had a very strong accent that made him difficult to understand.  So, sometimes, I would have a clue what was going on, but then would space out and lose track completely.

In a few weeks, I will be in the room with the rest of them.   All two of us and the lecturer.  I will miss being able to spin and galavant as I please, but it will be safer, me thinks.

It is funny how the technological age has made it easier for us to stay in touch and do things like distance learning and yet separated us in another sense.   I am glad for the convenience, though.

People in Medicine Say the Darndest Things

Remember that show, “Kids Say The Darndest Things”?

I do.  I loved the show when I was a kid.

Well, I think we should make another one… “People In Medicine Say the Darndest Things.”

Because we say some really stupid and funny things on a day to day basis that really don’t make a whole lot of sense when you think about it.

On a regular basis, we ask people invasive questions that are socially unacceptable to ask people we just meet.  It is part of the job.  But, when you think about it, it is odd.  On the same note, we make people disrobe, poke them in all kinds of strange places and speak in a latin-english mix throwing in random people’s names throughout.  It is almost like physicians, were in not for the job and training, they would be the craziest people in town.

Many physicians live in another time zone in their head.  They are late even when things seem slow.  And yes, they are very busy, but yes, some people do just need to invest in a watch.  It is like they fall into a strange time suck unbenounced to others around.  Some are oblivious to this.  They are the funniest ones to watch apologize or fail to apologize (not that I at all condone lateness… This habit is one of my biggest pet peeves).

This is one of the few professions where you can basically wear the comfiest and ugliest clothing to work (OR scrubs) complete with a strange hat and booties and people will think you are awesome.  I hate OR scrubs… In case you didn’t pick up on that.  I can’t explain it.  Something about ill fitting clothing worn by a million other people.

Then, take descriptions of disease presentations…. Red currant jelly stools intussusception (when the bowel twists around itself).  Then, there are blueberry muffin babies.  Kids that look disturbingly like blueberry muffins because they have extramedullary hematopoiesis (they are making blood in places other than bone marrow (like spots under their skin).  This is not a good thing.  It is a sign of nasty things like Rubella, CMV and a childhood cancer called neuroblastoma.

We had a patient come in today with a very large base of tongue tumor.  Their voice is muffled and kind of altered as a result.  The doctor says to me while in the room with the patient that he has a “hot potato voice.”  This means he sounds like he is talking with a mouthful of hot potato, appropriately enough.  Often this is used to describe a presentation of peritonsillar abscess.  Needless to say the patient and his wife thought this was a bit odd, using such a term for a voice change.  So, I explained and then they thought this was quite entertaining (after they realized we weren’t being derogatory in some way).

This creeped me out a bit and made me sad a bit. But, it illustrates the weirdness of the use of expire.
Image via scottpageazyoga.com.

Then, like food, we use the term expired.  I shouldn’t say we.  I refuse to say it, or write it.  But that is what the computer system says.  When someone dies, it doesn’t say “deceased” or “died on x date.”  Nope.  Expired.  Kind of like a carton of milk.  Almost as if to say we have expiration dates (I suppose we do, but really, it seems odd to say someone expired when we have other less cold words to say… Its not quite like we throw them out when they expire).

Weird things.  Unusual people.  A strange fixation on food.  Stuff that medical people do and say is just plain odd.  But, it is part of the job or lifestyle or culture or a bit of all of them.  Taking a step back makes me think about how funny little snippets of days in a hospital can be.

Choices

Today, I saw a patient who has a potentially curable cancer.  They live far away and would have to travel a great distance for treatment, so we offered admission to our hostel.  We explained everything.  I spent about 20 minutes explaining that it was a big tumor with positive surgical margins, but that radiation would decrease the local recurrence riskto less than 10%.  And chemo would decrease recurrence systemically.  Good odds.

He was well.  Elderly, but well.

Yes, the treatment has side effects.  Significant ones that are still easily managed.

And he took in what we said.  His wife listened.  And at the end of our conversation, I asked him what he thought and he said, “no.”

I am a big proponent of people having autonomy, but I had to ask why.  He said he didn’t want to travel and stay here.  He wanted to be home with his wife.

We reiterated that after the 7 weeks of treatment, he can be home all the time.  He may have years.

He responded that he may not.

He is a competent person who can make his own decisions.  His wife agreed.  They had talked about it before.  No treatment after surgery.

They asked about time.  We don’t know.  The tumor was slow growing, but there was some left behind.

I agree with his decision.  I would take treatment if it were me, but it wasn’t me.  And people have choices.  And he made his choice.  I am glad he had the gumption and courage to actually say what he wanted instead of just going along with the doctors and being miserable.

It is funny, some people beg for treatment.  Treatments that will almost inevitably offer minimal benefit.  Treatments that cause pain and suffering and even hasten the death they are trying to avoid.  They clamour for any experimental drug.  And I get that.  We all have a drive to live.

But, then you contrast it with this couple.  A theoretical potential cure.  A definite, statistically significant increase in disease free survival and overall survival.  Turned down because the travel is unacceptable.  And it wouldn’t be quality of life.  This while so many trade their quality of life for brief periods of extra time.

Some might argue turning this type of treatment down is putting themselves at risk.  Suicide even.  But, really, it is the same as choosing to take antibiotics for an infection.  The infection might kill you, or it could just get better.

Socially, this guy is braver than the people who fight for the cure.  Societally we put a lot of emphasis on cure and avoiding death (not that his death is impending by any means).  People, however, see this as a loss.  He failed to take treatment.  The thing is, he made a choice because there are things in his life other than health.  He understands that.

People are fascinating.  I can’t say for sure what I would do in these situations.  But, sometimes I wonder why people choose the way they do.  And why some people expect so much and others so little.

I hope he enjoys his time with his wife, whether it is months or years.  I hope he never comes to regret his decision.

I respect autonomy.  Sometimes things like this make me sit back and think.  Especially when outcomes could be so very different with a different decision.

Wordless

I ran out of words.

At least that is how Patrick explained it to me.

I came home from a ridiculous day at work and I was strangely silent… Especially for me.  Because I was tired.  And hungry.

He explained that he once read somewhere that women generally use more words in a day than men.  And that I must have a high word quota based on my job and the amount I generally banter on.  However, my silence was a sign that I must have reached or exceeded quota.

Kind of makes sense when you think about it, I guess.

I don’t think there is an actual number, but after so long with people and being social and chatting away, there does come a point where I don’t feel like talking anymore… To anyone.

In fact, I was so tired last night, I didn’t even want to pray.  Bad sign.  I was just so sick of talking (I did, however, wind up having a lovely evening at a bonfire with good friends… and crashed even more thereafter).

It is good that God doesn’t have a word quota  Or we would all be in trouble.

In school, I remember having to write papers and there would often be a recommended word count or a minimum and maximum.  I must confess, meeting the minimum was never really an issue for me.  My problem was always the maximum.  I would edit forever.  Or, if it were page limits, I was the master of altering letter spacing and line spacing ever so slightly, so as to not be busted for being a bit over.

Talking can be like that too.  I am a fast talker to fit more in at once (at least that is one advantage to being a fast talker, particularly on oral exams).

Like in papers, once you run out of things to say, though… That is the end.  It is tough to stretch things out beyond a natural ending point.

I guess that is what happened to my speech.

Some good alone time and sleep will remedy that, I am sure.