Nightmares

dinosaur skeleton outside the Field Museum in Chicago

“Get your jammies on, please. Bedtime!”

“But mommy, I want to wear this!!!!” 

She was standing in the doorway to her bedroom, hand on her hip, wearing hot pink leggings and a long sleeve Hello Kitty T-shirt.

“Why can’t I sleep in this?”

A thousand retorts flew through my mind, none of them really any good, but at that moment it struck me that this was about control. For both of us.

I want to control you.

The reality is not that pajamas help you sleep better. AND, I had to concede that pajamas would not be not more comfortable than what she was wearing. In truth, I suspect pajamas are actually a plot by the clothing industry to force us to spend more money. Like “girl” toothpaste and “boy” toothpaste…

“Please, mommy?” she pleaded.

So who gets to have control in this situation? Me, because I am the “authority”? Should I enforce the rules because if I let the little things slip, it would pave the way for letting the big things slip? Why IS it a rule, anyway? Should I let it go, choose to pick my battles waiting for something bigger? Is it a better lesson to show we can change stupid rules? 

If I don’t have her change, I can get her down for bed all that much faster…

Bedtime.

Screw all of the philosophical mumbo-jumbo. I choose getting to bed. Quickly. Painlessly. 

That is my control.

Maybe I can convince her to wear leggings and Tshirts every day….

A Day of Patient Comments

carvings, Field Museum in Chicago

She looked me up and down disapprovingly. “Doc, that scarf. You need more color. Too much black and brown today.” 

Several hours later, a different patient… Same scarf. “Doc, you look so gorgeous! I adore that scarf!!!”

“Doc, we love your butt! We could just eat that butt up!” From two grown women in with their elderly mother. 

“Oh, Doc, I know it’s a benign skin lesion. I’ve got another one over here. I just wanted you to hold my leg like that. Made my day. My year! I might be old, but I’m not dead…”

“Doc, I am glad to see you don’t drive a sissy sports car!” Yelled across the parking lot by a patient as I was getting out of my big black pick-up truck.

“The only good thing about coming to the doctor is that I get to see you!”

Pan, at On The Road Cooking, asked about best patient one-liners. These are a few. I’ve done a bunch of other posts over the years with funny things patients say. While some of the things may seem shocking to you, I am used to it. Provided they are not being ugly, I just let it go. 

Fiction Friday will start next week!

In the Nick of Time

interior, Shed Aquarium in Chicago

It was a lovely spring morning. We were outside on the back porch coloring in a circus themed coloring book. Road construction was going a few streets over and a loud thumping repeated, shaking the ground as the workers broke up the concrete.

“Do you hear the elephants?” I asked.

My toddler son nodded, his eyes going wide.

“I think they are coming here! Let’s get some peanuts to feed them!”

He nodded his blonde head vigorously, grinning from ear to ear.

I ran inside and grabbed a bowl, pouring some peanuts into it. 

Then I saw the cashews. 

I’ll throw some in for fun!

I ran back outside and showed him the bowl of nuts. He grabbed a handful, as did I, and put a single cashew into his mouth. He chewed it, still smiling, and then swallowed.

Within seconds, his face turned ashen and his eyes were vacant. He stared off into nothing and would not respond to me at all. He was breathing was labored. His pulse was thready.

Then the hives appeared all over his body and he started to puke.

My son was having an anaphylactic reaction to cashews. 

He survived.

After that, I purchased an epipen and kept it on hand, just in case. 

He has had subsequent severe reactions to pistachios and kiwis. 

I say all of this to say that when I paid for the epipen the first time, it was $150 for a pair of them. Each year, I buy a new epipen to replace the expired one. Each year, the price goes up. Each year, I never have to use it I am throwing away hundreds of dollars. I hate that. Still. It’s my kid we’re talking about here. What kind of parent complains about spending money to protect their kid, right?

The other day I had a patient tell me that they just could not afford the cost of the epipen for their own son. With their high deductible plan they would be paying over $600 for a medication that they would hopefully never have to use. The price increase didn’t really matter so much to patients until the high deductible plans started to become the norm. The price difference before was picked up by insurance companies. Now, it is the patients getting stuck with it.

Yesterday, I ran across this article from the Washington Post about the soaring cost of epipens. Epipens have been around since 2004 but the cost has increased over 450%.

One quote in particular stood out to me:

Mylan (the manufacturer) itself is tight-lipped about the cost increase, saying only that it “has changed over time to better reflect the multiple, important product features and the value the product provides.”

So just how much are you willing to pay for your child’s life? For any child’s life? For a grown up’s life? Because that is what “value” is referring to here. They are holding my son’s life, your child’s life, for ransom. As for important product features…. it injects epinephrine. With a needle. 

Meanwhile, Heather Bresch, the Mylan CEO who has been with the company through the epipen price hikes, has had a substantial pay increase. Her salary in 2007 was  $2,453,456. Last year it was $18,931,068. Which makes me ask the question, how much money does she need?

Dearlilyjune asked what I thought was the greatest health crisis of our time. This is it. The sky rocketing cost of medical care. Pharmaceuticals. Imaging. Hospitalizations. Charging exorbitant amounts just because they can. There is nowhere quite like healthcare where they have you by the balls. Want to live? Want to have a good quality of life? Great! Pay some fat cat through the nose.

It is the worst in the US right now, but I figure it will be only a matter of time before this sort of thing catches on elsewhere. You cannot argue that the strategy makes money. It’s legal, even if it is unethical. 

Greed is powerful.

Flawed 

There are a surprising number of physicians who blog. I loved this post from Deconstructing Doctor about how it feels to potentially miss something, how it can eat you up, how isolating the medical profession can be. Check her out!

deconstructingdoctor.com

broken-saint-1422381-639x573I don’t always do the right thing.  I don’t always figure it out.  That’s the worst part of this job.  The not being perfect part because not being perfect means I’m flawed and flawed people make mistakes and my mistakes can hurt people.

One time I almost missed a lung cancer.  Oh God, the gut-wrenching weekend that I spent after that one.  I must have lost 5 pounds just from the nausea that I felt.  How could I eat?  How could I breathe?  My mind ground the details of the entire chart into a fine powder and then I sifted through that.  Trying to account for every dust particle.  How could I have failed so miserably?  I could have just died.  Truly.  What a miserable wretch I was.

The crazy part is it couldn’t have been helped.

She had lung cancer a decade before.  It came back.  My angst came…

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The Calling

Chicago skyline from Sears Tower in black and white.

She hesitated, staring at the caller ID.

There was only one person who would call her personal phone from that number, from that office, and in actuality she was not sure she wanted to speak to him. She stopped referring patients to him or anyone in his group long ago, specifically to maintain the distance they both needed.

Distance that had persisted until the apparition began to show up, unbidden and unwelcome. Haunting, attacking, cursing, taunting…. trying to drive her over the edge.

Why don’t you just jump? You worthless, crazy whore. Slut. Slut. Evil, insane, unworthy whore.

The phone rang again, vibrating in her hand.

Then again….

You don’t even know me.

She groaned, exasperated with herself because she knew she would answer. Of course she would answer.

She always answered. Curiosity was her nemesis.

“Hello?”

There was a pause. She closed her eyes, bracing herself, not sure what would come next.

“I’m sorry,” he said. “I let things get out of hand.” She had not heard his voice in… she couldn’t remember when. “I wanted her to hurt you…. because….” He trailed off into his customary silence. 

He had always wielded his silence like a sword, slicing his way through her. It was one of the things about him that drove her away.

“I know,” she said finally, even though she didn’t know. She didn’t really understand anything. 

Some secrets are best left shrouded in silence.

“It won’t continue,” he said. She could hear that he meant those words.

He might have said more but she wasn’t listening. The truth was she did not need anything more. She didn’t even need the apology. All she needed was for him to be the man she thought he was so she could go on remembering him as she always had…

Flawed.

Loved. 

And very far away.

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I am going to do “Fiction Fridays” so expect to see these vignettes and short stories on Fridays in the future! I had to use this one today as I have several posts I am working on but nothing actually finished and publishable to my satisfaction. The start of the school year yesterday plus catching up at work after vacation is kicking my butt!!!

Gravitational Pull 

giant ringed planets hanging from a glass ceiling at Adler Planetarium in Chicago

I like sex. 

I am a really, really big fan of sex. 

Good sex.

With the right person at the right time, an orgasm is the most deliciously exquisite thing you can ever experience.

Jane, though, asked me what I would say to my kids in 10-13 years if they come to me saying they wanted to have sex. 

Several things….

First, I really DO hope my kids feel they can share that with me when the time comes. 

Second, I hope I can be rational about my response. I will admit that I have serious, legitimate concerns about my staying calm.

Third, I hope that someday they get to experience some really great sex.

By the time they are considering sex, they will already be so sick of listening to their doctor mom talking about STDs, after I show them picture after picture after of the ravages of disease, I won’t even have to say anything more about that.

To my daughter I would say that our first time having sex as women is a very emotional act and ties us to that other person forever. The people in between? Meh. That is hit or miss. Choose wisely with this first one because you will have them in your head, and potentially your heart, forever. 

As women, we bear the brunt of childbirth, child rearing, and disease. Engaging in sex is an expression of self sacrifice… symbolically and often literally giving your life and your future to another person. It can be a beautiful thing or it can become a very painful nightmare. 

And I would also advise her that it won’t be fun, that first time. Painful physically, yes, but not fun. She likely will not achieve orgasm, because let’s face it, boys in that demographic are piss poor lovers. She will have way more fun if she waits.

To my son, I would say many of the same things I would say above. I would also tell him that love is not sex and sex is not love. Some girls do things they will regret because they are desperate for love and they don’t understand the difference between the two themselves. 

I would tell him that controlling himself and his desires and urges is a key part of becoming a man. Control is sexy. Strength of character is sexy, sexier even than physical strength. 

I would make sure they both know how to protect themselves properly from pregnancy and disease. Then I would step back and pray that what I have taught them over the years sticks with them and guides them to good choices.

Am I Dreaming Yet?

dinosaur hanging from the ceiling of the Field Museum in Chicago

It was 4PM. I snapped awake at the desk, looking around quickly to see if anyone had noticed my moment of weakness. 

No one was watching.

Relieved, I continued to dictate the patient’s discharge summary. As words tumbled from my lips, I realized they were not making any kind of sense. I stopped the recording and replayed what I had just said.

A bunch of gibberish.

I tried again, rewinding back further. Still gibberish. 

Fully awake now, heart racing, I trashed the whole dictation and started over again, jotting down a quick outline so my brain would not get lost.

My whole body ached from the fatigue. All I wanted was a bed. Nice cool sheets. A fluffy pillow. Maybe a soft blanket or two. Darkness would be nice but was not critical.

Then my pen started to laugh at me.

Wait. 

Was that a dream or a hallucination? After 38 hours of awake, I was no longer sure…

It was the very first hospital shift of my intern year of residency. I had never been up that long at one stretch before.

When people talk about how hard residency was, this is what I remember… the bone aching fatigue. When I was moving, things were better, so when I was on the hospital service I got into the habit of dictating and writing orders while standing up instead of sitting down. I think I got used to the sleep deprivation, if you can imagine. 

Resident work hour restrictions went into effect my last year of residency. Rather than coasting to graduation, letting everyone else cover call, I found myself covering intern and second year primary calls overnight at the hospital, filling in their gaps. My class worked much harder than anyone before or after us. We were caught in the middle.

Interestingly, while everyone believes work hour restrictions save lives, what they don’t realize is that it has increased medical errors from more frequent hand offs. When you go off duty, you have to check out your patients to the next physician. It is not possible to discuss in detail every event of the preceding shift, so you give a short summary. It is thought that the more frequent hand offs, increasing those lost details, has caused an increase in medical errors that cancels out the fewer errors from sleep deprivation.

So in the end, it’s a wash. 

Seriously.

Personally, I think the longer hours made me tougher, taught me that I could do and survive much more than I ever thought possible. It reinforced my work ethic. It exposed me to a lot more medical knowledge than I would have gotten otherwise. It helped shape me into the person I am now.

Does that mean we should go back to insane work hours? 

Not necessarily. 

Sleep deprivation clearly does increase errors, but that isn’t the only source of medical errors. We need to drill down on those. We need to figure out better ways to do patient hand offs. We may need to add a year to family practice residency in order to get the proper exposure, to ensure we are graduating solid physicians. 

I love that people are looking at these things more closely now, identifying where errors are coming from, but dang if we don’t move painfully slow on this front. Work hour changes in the U.S. went into effect over a decade ago…. Seems like we should have a better handle on this by now.

In a Bubble

the

My daughter said this afternoon, “Mommy, do you remember when we saw that dead rat on the street and its stomach had exploded and its guts were moving? Why were its guts moving?” 

Um. I’m not sure it was guts….

That made for an interesting discussion with a five year old in the middle of downtown Chicago. She won’t remember the museums or the parks or the Sears Tower. She will, however, remember the maggoty rat in the street. 

No matter how hard we try to create good memories, the most memorable are the accidental ones.