Eroding

Cambodia 546

“I went to the drive through and got the biggest thing of popcorn chicken they sold and I ate every last bit of it in the car.” She had that numb, dead look in her eye that I had seen before. “Then I pulled over on the side of the road, stuck a finger down my throat, and made myself throw it all up.”

“You’ve done this before?” I asked in disbelief. “You are bulemic?”

She nodded. “Since I was a teenager. I hadn’t done it in a year or two, though.” I had been seeing her for over ten years and not an inkling of this was ever spoken of before. 

No clue.

“Why did you do it this time? What the hell happened?” 

“That new pulmonologist you sent me to? She’s as skinny as my pinkie. She says to me as soon as she walks through the door, before we talk about anything else, ‘You are obese! You need to lose weight. The only way you will be able to lose weight is by having bariatric surgery.'” 

Tears were starting to roll down her face. I handed her the Kleenex box.

“The thing is, Doc, she doesn’t know me from Adam. She has never met me before. She didn’t even try to get to know me. She just looked at me like I grossed her out.”
“Did you do any more binging and purging?”

“Every damn day since that appointment.”

Years of slowly getting her to change her diet and lifestyle, getting her to start exercising (using that nifty mini-elliptical machine I wrote about before), getting her to lose weight in the healthy way…. It had translated into her actually losing weight for a few months. Twenty pounds.

ALL down the drain. 

Often, when we think we have someone’s best interests at heart, we have no clue what they really need. It is easy to forget that a few words can tear someone down so thoroughly, so quickly. Thirty seconds to undo 11 years of work is a sobering thought. 

With the ACE study linking severe obesity (and even autoimmune diseases) to childhood trauma, evidence now of a genetic link to being overweight, the realization that the bacteria in the gut are different in people of different sizes…. There is much more at play here than someone simply having a sloppy lack of self control. 

Kindness. 

Remember kindness. Always, always kindness.

You Misdiagnosed Me…

IMG_9439

Sometimes finding the right diagnosis is a process. The horses must be ruled out before we can go looking for the zebras. Or, maybe you are not far enough in the disease process to present the right symptom clues.

Do you know how many things can cause fatigue?!?!?

We do our best. No physician wants to miss something. 

Call it pride if you like. We want you better because we don’t like to watch you suffer but also because it makes us look good.

We don’t have a crystal ball. 

Personally, I would pay through the nose if you have a lead on a good one…

Sometimes we get it wrong. 

We are imperfect humans, after all.

That does not mean we don’t care.

Let it Fly!

  
The pants I wore yesterday were not flattering at all. Not one bit. I knew this when I put them on. I didn’t like them when they arrived on my doorstep after ordering them online and I do not like them now.

In fact, they have been taking up space in my closet for nigh on two years now because I could not ever bring myself to wear them out in public. As it turns out, it is very, very difficult for me to get rid of things I have never worn. I feel terribly guilty (Perhaps a throw back to the fact that as a kid my clothes all came from Goodwill?) so I hold onto them in the hopes that something someday will change. 

Maybe they really aren’t that bad? I only have to wear them to find out. Yet, I have pants that I really do like so I wear them instead. But still, maybe? And so on and so on.

Dust collects.

After going through my closet last weekend, I decided to go ahead and just wear the stupid things so I could get it over with.

Done!

Of note, there is nothing like a bad pair of pants to throw you completely off your game and no manner of fancy panties can remedy that fact.

Those pants have now gone off to the throw away bin. I will not inflict them upon someone else! 

Hold On To Your Pants!

 Old steam engine at the depot. 
I have been going through my closet with the intention of updating my look for the clinic.

There are two things I have to say:

#1, Thank the heavens above that wide leg cropped pants are now back in style. I loved them then and I love them now.

#2, Thank heavens I did not throw out the ones I used to wear 7-8, even ten years ago. (How long ago was that exactly, anyhoo, and can I call them “vintage” now?)

Woohoo for clothes hoarding!!!!

Also, if skinny jeans come back around, I will be completely out of luck…

Hidden

  
“Well then, doc, I think I need to tell you something….”

“Ok.” I waited. I could tell from the look in her eyes this was going to be bad.

“So, I was having a cavity taken care of a few weeks ago when the dentist stuck herself with the needle. They told me that I had to get tested for diseases. So I did. I had my blood drawn. It came back positive for HIV.” 

She paused for a moment not sure what to say next.

“So we need to set you up with an infectious disease specialist, huh?”

“Yeah.” She ran a hand through her hair. “I need someone who is really good. I’m scared.”

She looked normal. She didn’t appear ill. There was nothing about her that screamed out, “I am high risk for HIV!” 

She never would have known about the HIV if her dentist had not made a mistake and then admitted it and then gotten her tested.

And there was now a dentist somewhere who was worried that she might have contracted HIV herself. Was she taking meds? Losing sleep? 

I remember listening to a physician who said she had contracted HIV from a needle stick. She was talking to us in medical school about the importance of safety measures on sharps, of being careful. We all thought she was such a loser. We would never make such a stupid mistake. It would never happen to us, you know?

Until it does.

We all get stuck.

Three times for me, so far. I remember each. Once while placing a central line in a gravely ill patient with sepsis. Once in the OR during an abdominal surgery (the surgeon’s fault actually, I was assisting). Once after injecting a joint in the office.

There is the wait. What is lurking, hidden in that blood? My blood? Pain. Sure it hurts. But will I die?

Clouded

 Ship mast in black and white. 
“So, I am the manager at that other clinic right by you.” The woman regarded me haughtily.

“Oh, right… Nice to meet you…” I turned and scribbled my name on the sign in sheet.

“We are sort of in competition… in a way.” She half smiled. “It is nice to be able to put a face to a name, doc. I hear a lot about you from patients that come over.”

I stared at her. 

I had had a terrible, super crazy day. She was The Competition? Hell. Some days are so emotionally depleting that it leaves me numb and incapable of dealing with snarky small talk.

“We are overrun with patients. There is just no way we can take care of all of them. You are welcome to anyone you can steal.” 

Truth. 

“Oh. Well, we have the same problem. We are waaaaay too busy.”

Sure.

I walked away so I would not say something I would regret.

Then I located my own office manager. We had been summoned see how much money the new EHR was going to cost us. 

It is “optimized” for a 24 inch screen. They “strongly” recommend a computer on a retractable arm in each room. That will cost close to $3000/exam room. Plus each staff member will need a new computer/monitor. Plus the physicians will all need laptops to take home and a docking station with the 24 inch screen in their offices.

Cah-ching.

The tiny, poorly designed exam rooms in this godforsaken clinic I inherited are so cramped that I fail to see how this is going to work. Bolting it the wall? 

Where exactly?

And why?

Why can’t they optimize it for equipment they know everyone is going to have anyway?!?!?!! I still welcome the change. It is long overdue. 

Still.

Don’t pay attention to cost, they said. Just pay attention to work flow, what will work best for you. The cost will be capitalized….

How can I not pay attention to cost?!??!?

Let Go

 beach at sunset 
Whenever my son swims, I have flashes of him lying in an ICU bed, intubated. 

Some prick of a neurologist will tell me that my baby is brain dead and I will hate that man forever because of it. I will wait to have someone wheel his body off to harvest his organs. My heart aches with a deep despair and my eyes sting with the promise of tears not yet cried. 

I want to hold on to him.

Don’t go!

There is a smell that patients get when they are gravely ill, in ICU. I smell it over the chlorine. I hear the beeps, the psht…psht…psht of the ventilator instead of the splashing of water and squeals of joy. I can feel his tiny lifeless hand. It used to squeeze mine…

“Mommy! Watch me!”

I want to follow him to the deep end. I want to keep a hold of his swim shorts just in case. Watching from a distance is not good enough. 

I don’t want to loose you.

“Mommy! Are you watching?!?!??”

I am. 

I am watching. 

He is brave. I don’t want to steal his bravery, so I watch from that distance. I wave when he gets to the end as he wipes the water from his eyes, beaming at me. It is hard to love someone that much and not want to smother them.

The ICU pops into my head again as he swims back. I hate that I know the other side so intimately. Countless children die like that each year. Mine could be next. He is just like all of those other kids. 

I miss him already.

“Mommy, I love you.” He has me wrapped in a giant, very wet bear hug. 

Can you see it in my eyes, this battle I wage every day? Wanting to protect you but instead stepping back and letting you have the triumph of that skinned knee, or that bruised rib? If something happens to you I am afraid I will not survive. 

But I let go. I have to.

The Schmear Job

 interior of a green Caboose 
“You have never had an abnormal PAP before and your PAP and HPV screens last year were normal so you don’t have to do a PAP this year!”

I expected to hear a celebratory, “Woohoo!” Instead, she scrunched up her face and regarded me suspiciously. “No. Really?” She sounded doubtful.

“Really!” I smile back at her. 

“Yeah…. I don’t know about that. I am used to doing them every year. That’s what my OB always did.”

“These evidence based guidelines have been around for years. I cannot speak as to why your OB was not following them. I reviewed those records. You had no history of anything abnormal. You just told me that you have not had any funky discharges or abnormal bleeding. No new sexual partners….”

“I still want to do a PAP.”

“Why?”

“I just do.” She sighed. “Look, my friend just had a PAP with her doctor. She gets one every year. Why did she have to do one and you are telling me I don’t have to?”

I have had countless conversations like this. Variations are: Accusations that I am lazy. Or stupid. Or I am trying to kill them. Or that this is a vast democratic male governmental scheme to save money and kill women.

Sometimes we do such a good job educating patients that to reverse that ingrained notion is a major uphill battle…

Bummed

  

“Doc, my knee has been bothering me for a few months now. It began when I started doing lunges in crossfit.”

“Did you stop doing crossfit for a bit to see of it would get better?”

“No.”

“Have you been taking any antiinflammatories?”

“Uh, no.”

“Icing it?”

“Well, no. I know I should do all of that, Doc, but I just haven’t.” Cue nervous laugh. “Can’t you just fix me?”

At this point, invariably, I laugh back good naturedly and say, “Well, guess what we are going to start with first…”

It struck me the other day while listening to some audible crepitus and wincing with pain as I took the hotel stairs because of a nonfunctioning elevator, that I have been nursing my own bum knee for a few months. Of note, I have not been resting it or icing it or taking any meds. I still sit at my desk and vigorously pedal away on my mini-elliptical contraption while I am doing charts every day at the clinic, even though the pain and stiffness are more pronounced when I stand up afterwards. Even though my knee is not getting better. It is, in fact, getting worse.

Sometimes I even limp.

So I considered this fact for a moment. Why am I engaging in the very same behavior that my patients are exhibiting that drives me nuts? I should know better, right?

Denial. I don’t want to admit that I have a problem, so I ignore it. Because to have a problem means I have to accept my own finite existence. Surely it will just go away? Eventually?

Time. I am too busy. I do not have spare time to spend taking pills and applying ice. Maybe I should actually call it Lazy.

Stubborn. I am too tough for this to really affect me. Pain? I scoff at pain. 

Fear. What if I really do have a problem? Surgery? Knee replacement? OMG. How will I burn calories if I cannot exercise while I work? Will I gain weight? How will I find time to do some other form of exercise?

Attention. “Doc, what happened to you?!?!!? Why are you limping? Here, let me help you with that…”

So, ok. Now I understand. It just took some time for my smug, know-it-all self to live this so I could truly appreciate and respect the nuances at play here. 

Lesson learned. 

Sort of…

Do you know what I am doing right now as I type this out? I will give you a hint: It does NOT involve ice or pills or rest. I am pedaling on that damn elliptical machine.

Alright, alright! I am stopping now. Well. Maybe. I’ll just slow down. Some.