Inside My Heart

Sacre Coeur in Paris, France

I see you in places I never expected.

Sometimes your eyes are staring back at me from the face of a stranger. You walk past me, your gait now belonging to another. I see the way your hand moved, the twist of an eyebrow, your laugh, the determined set of your chin, only…. it is not you.

Stolen.

They have all stolen you.

I don’t know if I should love all of these people or hate them.

Perhaps the better question is do I love or hate you?

Grave

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I had something rather upsetting happen last week:

A patient, old enough to be on Medicare, came to the office with acute onset of left lower quadrant abdominal pain a few days earlier. It was getting worse. The pain was constant and bad enough that she had a difficult time standing up straight. She denied constipation or diarrhea. No black, tarry stools. Her temp had been 100.0, not quite a fever. Her urine test was negative for bladder/kidney infection.

It was a Friday afternoon. These sorts of things always happen on Friday afternoons. I checked the time. Fortunately, it was early enough we could get a CT scan done STAT and hopefully save her a trip to the ER. My staff arranged it and she went over to start drinking the contrast.

About two hours later, I got the call. It was diverticulitis. No abscess. No perforation. No cancer.

Awesome.

I called the patient, got her started on the antibiotics, and told her that if things got worse she needed to go the emergency room. I saw her back on Monday. 

She was doing great, the pain was gone.

Score one for the win column!

On Thursday, though, I got a fax from a company contracted by that patient’s Medicare replacement insurance who had reviewed my documentation and decided that her CT scan would not be covered until she had failed a course of antibiotics for seven days first. They also wanted me to know that they had sent a letter to the patient notifying her that the scan would not be covered because it was not ordered appropriately.

Your doctor sucks so now you have to pay…

WTF?

My first feeling was confusion. Did I do something wrong? Had there been a change in the management of a first case of suspected diverticulitis? Some new paper that I was not privy to? I scoured all of my references. I asked my partners. I even Googled it, folks.

Nothing.

My second emotion was anger. Here’s a vulnerable population, the elderly. Now the patient, who is on a fixed income, was going to get stiffed for a couple thousand dollars because I did the right thing. If I had just sent her to the ER, they sure as hell would be paying a lot more for that CT scan, as well as paying through the nose for a crap load of expensive blood tests, IV fluids, meds, urine tests, and the ER physician’s bill. They would not be sending denial letters to the hospital for that CT scan. Oh, no. 

How DARE they make me second guess myself! I thought we were all trying to keep patients out of the hospital?

I fumed. 

My head hurt with the rage. 

When I got a chance, I called them and spoke to a “medical director”. I have no idea what his qualifications actually were. He did not identify himself as a physician.

“Has the patient had a prior case of diverticulitis?”

“No, never.”

“Do you have anything else to add before we make a decision?”

“What? Aside from her severe abdominal pain? No.”

“Let me go ahead and give you the approval number for that scan.”

Thanks so very much.

Why was the scan denied days after it was ordered, after we already had results? Why was it even necessary for me to waste my time fighting their decision when I only had to answer two stupid questions? All of the necessary info was in my office note, a copy of which they had been provided with prior to the scan. Why was it necessary to tell the patient their study was denied without first giving me the opportunity to fight it?

They crossed a line.

In a month, I may order 1-2 CT scans, maybe 5-6 ultrasounds. MRI’s? Maybe 5-6 in a whole year. It is not like I over use expensive studies when they are not going to potentially change what I do with the patient.

They keep databases on me.

I think they were secretly hoping I would not call, that I would tuck tail and run. I wonder how many physicians do, whether it is out of embrassment or ignorance, thinking it really is some new Medicare guideline they didn’t know about, or simply just from lack of time. Then, the patient would bear all of the cost, despite the fact it was a completely appropriate test. Saves the company tons of money, I bet.

This is what medicine has been reduced to, now.

I had a patient tell me recently that she felt doctors were in cahoots with insurance companies and the pharmaceutical industry because her endocrinologist told her that her new insurance company would not cover her medication, the one she had been taking for almost a year, the one that had finally gotten her diabetes under control, until she tried and failed their preferred drug. The new med made her feel awful. She was angry and no amount of explaining was going to change her mind. Since her endo had to deliver the bad news, she felt it was the physician’s fault for not getting the med covered. There must be money involved for that doctor. That, or the endocrinologist was lazy because they just didn’t try hard enough.

She isn’t the only one and you know what? I don’t really blame her. Making sense of all of this is hard for patients.

Why can’t we all work together to take the best care of patients? Why does there even have to be a bad guy?

Meanwhile, perpetuating the public’s mistrust of physicians, undermining care plans, is in the insurance industry’s best interest. I am afraid this is only going to get worse….

Glassy

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“Excuse me for a second,” I rasped, “I need to go get a sip of water.”

She nodded her head, wide eyes following me out of the exam room.

I ran into my office where I chugged some water, then wiped the tears from my eyes, checked my red face in the mirror to ensure no boogers were trying to creep out of a nostril, and walked back into the exam room. 

As soon as I opened my mouth to talk more about piriformis syndrome the coughs came hard and fast again. I held up my finger and pointed to the door. She nodded again, staring in shock.

This time, I brought the glass of water back with me.

“I am so sorry!” 

I was dosed up on a steroid, an antibiotic, and so much albuterol my hands were shaking if I held them out in front of me. I was not contagious at this point but the cough was terribly disruptive when these fits occured a couple of times a day. Aside from the fact that taking off for a cough seems so silly, when the wait time to get in to see me is 3-4 weeks for routine appointments, I simply cannot take off for a week or two for that cough to go away completely.

Somehow, though, a sick physician seems like a terrible advertisement. Like a hair dresser with a bad hair day. Or a skinny chef. They cannot be trusted, can they?

Maybe next time I get sick I’ll try that Vicks Vapor Rub on my feet at night trick that my patients swear by…

(Also, fear not, this was a couple of weeks ago, I am completely better now!)

Ambiguous 

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She wondered why her hair began to thin when she hit her early thirties. First over the crown and then over the rest of her scalp. A shiny pate that showed through the big hair no matter how the hairdresser swept it or curled it or sprayed it.

They never told her why her female parts never worked. Why she had to take hormones from the time she was a teenager. 

She had to adopt children. 

Her body wanted to grow certain ways, be certain things…. muscular, flat… Make-up did not help, not really. Neither did over compensating with clothes and hats  and flamboyant wigs. She dieted and starved, trying to achieve that ideal female form but it always seemed just beyond her reach.

She always wondered why she did not feel comfortable in her own skin. Why did she look more like her uncle than her mother? There was a lie lurking just below the surface, she could feel it.

Here she is now in her sunset years, decades later, still wondering. 

Chromosomes.

I can tell her the answer that they never did. But does she really want to know that the life she has lived maybe not be real as she imagined it? What would that mean to her husband? To her kids? That she is not who she thinks she is? That he is a she only thanks to a well intentioned surgeon’s knife in infancy *, thanks to parents and a society who did not know what to do with ambiguity?

Ambiguity is not simply swept away or cut away. 

It haunts.

What would the truth mean, now, when it comes to public bathrooms?

Ignorance and fear.  They also haunt. 

Who gets to decide what is male and what is female? How many chin whiskers is too much? How tall or stocky can you be to still be considered a woman when people look at you? How big can your breasts be before you are required to use the ladies’ bathroom instead of the men’s? Will anyone who is “questionable” have to carry around a note from their physician identifying their gender for bathroom purposes? Are people going to be forcibly removed from bathrooms because they don’t look “right”?

You think sex is all a matter of choice? That being transgender is a deviance, something evil, something to be afraid of? That transgender people are subhuman and do not rate the simple dignity of being able to use a public toilet? 

The world is not that simple. There is always ambiguity….

* Many cases of ambiguous genitalia in the past were treated by assigning female sex to the infant without taking into consideration the child’s chromosomes or hormones. Practically speaking, it was easier to make a vagina than it was to make a normal penis. Many of those people were never told.

Chased 

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“The first time I remember realizing I was fat was when I was about five years old. My mother had made me a beautiful pink dress for Easter and I was standing in the middle of the aisle at the dime store just twirling around and around…” 

Her voice faded away for a moment as the memory overtook her. 

“I was feeling so beautiful, just twirling. A older woman suddenly stopped short and exclaimed, ‘Well, aren’t you just the cutest, roundest little butterball I have ever seen!’ My father was there and started laughing uncontrollably. When he got home he told my mother, my bothers, and all of his friends. They laughed and laughed and laughed. He threatened to tie me to the tree in the back yard where the dogs were chained so they would chase me around and around until I lost weight. Everyone thought that was awfully funny, too, and the laughed and laughed some more…”

Anorexia has left her a skeleton. 

She does not hear anyone say she is beautiful. 

She does not hear anyone say she is not fat. 

All she hears is the laughter.

“Just Because You’re British”

  

Gibber of former Gibber Jabberin’ fame (you can see where she *used* to blog here) commented on my post Carried Away that she had a scary alcohol story. Since you can see that her blog is now defunct, I asked her to do a guest post. Please feel free to tell you how much you miss her and beg her to return to blogging. Maybe she’ll listen to you good people because she sure as hell won’t listen to me…

It was a Saturday night and the girls had all gathered to get ready for our night out on the town. There was excitement in the air. We were doing what girls do before they go out for a night on the town.  Curling irons flipped on, make up all over the bathroom counter. Our clothes were spread out on the bed so we could all decide what looked best on us.  

British accents were all over the place. You see, I was one of only 2 Canadians amongst a group of British nannies that had come over to Canada to work. I really didn’t hear their accents anymore since I spent a lot of time with them. I may have even had a bit of one myself.

This Saturday night while it seems at first glance like any other Saturday night on the town, it wasn’t.  We knew it wasn’t, but we didn’t know just how different it would turn out.

We were all in our 20’s so it took us a while to get ready. I don’t know why it mattered so much since bars are dark anyway, but it did. We all hopped into a car where my Canadian friend’s boyfriend sat behind the steering wheel. The only guy with us. Poor guy!

We hit the road, the road to Buffalo, New York. We were crossing the border from Ontario to party. 

Harmless right?!

I don’t remember how long the drive was, but eventually we arrived with no glitches at our bar of choice. We parked and headed in to dance our crazy butts off!

Now there’s something you should know about me. I was 19. I hadn’t yet done any drinking. I just didn’t. In Canada, I was of age to do so. In the US you had to be 21.

So I danced, and danced. I like dancing if you haven’t figured that out already. Could you guess, that doing all that dancing might lead one to get thirsty? I’ll bet you could.

Drinks were 2 for 1. Someone offered me one of their drinks. It was a long island ice tea. I thought it was only iced tea since we were all under age. It was a huge drink, and I downed it because of the aforementioned thirst. It was loaded with whatever alcohol they add to long island ice teas.

Guess what I did next? 

I danced and I danced some more, until the end of the night was upon us.

Our gang regrouped and we headed outside in the cold crisp air. That’s when that long island ice tea hit me, and hit me hard. I was so drunk I could hardly stand up. Well I really couldn’t. I think a couple of my friends were holding me up.

Just outside the bar was a hot dog stand. The only guy with us decided he was hungry. How perfect since there was a hotdog stand right there. He bought his hot dog turned around and a stranger out of nowhere said to him and I quote, “Give me your hotdog.” He and we were all a little stunned. He said, “What?” The guy didn’t ask again he just punched our friend hard in the face twice and I if I remember correctly took his hotdog. 

Our friend’s girlfriend jumped in front of her boyfriend to confront the attacker. Probably not the smartest thing to do, but you never know how you’re going to react when in a serious situation, and you have shock and adrenaline running through your system.

I’ll get back to my friend in a minute. Here’s where I need to tell you where I was at. I was so drunk I was laughing my head off. I knew the situation was serious but I wasn’t able to get serious because as I mentioned earlier, I hadn’t drank before. The alcohol possessed me. My friends were trying to get me to shut up and act “normal.” I could only keep laughing. I still couldn’t stand on my own. Part of me now, is glad I was drunk. Not the part that caused me to make the situation more dangerous than it was, but the part of me that would have been terrified had I been sober.

Okay back to the girlfriend. I left her standing in front of her boyfriend confronting the attacker. The attacker was gearing up to beat her up. He was ready to throw a punch. It was crazy scary. All of a sudden the attacker and his gang turned around and ran away. I was told that a police car had driven up.

You can bet we high tailed it to our car and got on the road out of there. Our friend was hurting but okay. He drove home. The others were just in pure shock and fear. 

I was still drunk.

We were very lucky. As bad as the whole situation was, if that cop hadn’t of come it would have been much worse. We likely would have been killed. I know this because we found out a week later, that 4 girls were killed in that same area by some similar appearing men that matched the description of our attacker and his friends that left notes on their bodies saying, “Just because you’re British.”

I won’t say I never made any other stupid choices over the years after that, but I will say I never again crossed the border to party.

Seeing Through

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“Remember, that meeting is at noon today,” the IM from my office manager read. 

“Meeting?” I typed back. I flipped to my Outlook calendar. 

It wasn’t there.

Damn.

“Yes, THE meeting…,” the window popped up on my screen again.

The patient on the exam table was telling me a long story about the death of his childhood dog. I nodded and made a sympathetic sound as he got to the really sad part. I had heard it a few times before…

“The one where they don’t want us to be working on our computers, the one where we are supposed to provide our undivided attention?” There were fifty-two items on my EHR’s virtual desktop right now with a full schedule the rest of the morning and a lunch appointment with a friend.

A bright spot appeared suddenly in my field of vision. Like I had stared at the sun for far too long. But it was not going away, the sun was not visible, and I had not been around any flash bulbs or used the ophthalmoscope on the wall.

I blinked a few times.

Still there. I sighed. 

Not again.

“That’s the one. And have you RSVP’d for the Saturday meeting?” he responded.

“I’m not going.”

“You know that it is strongly encouraged and if you don’t go you have to email an adequate excuse to the system president.”

The scintillating pattern started to develop further and wind its way across my field of vision. It was a struggle to type without errors.

“I am not going.” I typed again and hit send.

“Are you serious?” he responded. I shifted my eyes around and moved my head a bit to see his words around the growing hole in my vision.

“Yes,” I typed back then realized the patient was quiet, waiting expectantly. 

Story over.

I thanked the gentleman for telling me the story and quickly entered orders on his chart in case the ocular migraine was going to get worse before it got better. 

An IM flashed from the front desk flashed up to say that my 9:30 patient was 20 minutes late for their physical exam appointment and could I still see them? The rule is 15 minutes late you reschedule unless there are extenuating circumstances. They shouldn’t even be asking.

“Please have them reschedule.” I was already running behind because my 8AM had arrived ten minutes late.

“I see you are needing a tetanus booster. Can I give that to you today?”

He nodded.

I sent an IM to my medical assistant to alert her to give him the immunization.

Once that was addressed I did a quick exam. 

Luckily, you don’t have to see well to be able to listen to someone’s heart and lungs.

“We are going to change your blood pressure medication, increasing the dose. Schedule a follow up for one month but if you can call me with some home blood pressure readings in a week or two I can adjust the meds further if needed and get this controlled faster, saving you an extra visit down the road. Got it?”

“Sure thing, Doc!” He grinned.

I almost missed his hand when he reached out to shake mine, then I dashed out of the room.

My office manager was standing outside at the nurses’ station waiting for me, arms folded across his chest.

“They rescheduled the meeting to next week.”

“What?!?!??!”

“So mark your calendar right now…”

It isn’t enough that I touch an average of 110-170 documents in the electronic health record per day. Or that I get from 20-50 emails per day (half of those are about various EHR systems that are not working properly that day or about our numbers for this measure or that measure). Or that I address countless IMs from various staff members throughout the day. I have the attention span of a flea nowadays and THEY made me this way. Now I have sit through hours and hours of meetings “paying attention”to stuff I really don’t care about anyway? I am not sure I can do that without being medicated.

I really, really don’t want to do that.

If brains on video games are remodeled, what happens to brains on EHRs, I wonder?

Is all of this why my ocular migraines are back?

Some Little Things

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7AM this morning.

I just finished one of the more challenging call weeks I have had in a long while. The volume of calls was one issue it was not the problem so much as the timing of the calls.

For instance:

Two calls came back to back as I was packing up to go get my kids from school, already pushing the envelope where if I don’t pick them in the next ten minutes they were going to be given away to some other family.

Another came when I was getting the kids buckled into their seats in the school parking lot. 

Several came during the 30 minute drive home, requiring me to pull over and address them.

While trying to get dinner ready for two very hungry kiddos. Several while eating dinner.

In the midst of homework, piano,  readers.

Several nights as I was getting the kids ready for bed. 

All day long on Saturday…

Don’t get me wrong, taking call is part of my job. I get paid for people to have access to me at all hours, to miss out on the things I want to do instead like catching up on Game of Thrones. It is what it is. 

My kids, however, do not understand that there are times mommy has to be a doctor first and a mommy second. Typically when I get a call they act out. 

Screaming, crying, fighting, begging…

“Please, don’t go, mommy! Stay and hold my hand just one more minute.”

I understand why they do it, why that is the exact time that they desire my attention most. Jealousy. Someone else gets mamma’s attention and that is not cool. But understanding does not make it any easier. 

The whole thing is exhausting and I hate it with every fiber of my being.

This week, though, they both seemed more at peace. They wanted to “help” but they didn’t fight it. They did not throw screaming fits. They sat quietly, snuggled up next to me, and waited. It was almost pleasant. 

So much less stressful. 

That helped me tremendously.

Maybe they are finally old enough to understand? 

Maybe.

But…

I picked them up early from school the Thursday before my call week started and told them that I had informed all the sick people they would just have to figure something else out because I was taking my kids to go get hot chocolate instead. My son and daughter repeated this to me over and over again, laughing gleefully, as we sat on the porch of the coffee shop sipping away. 

“Tell us again what you told those sick people, mommy!”

It made an impression.

Maybe they just needed to know that they could be more important sometimes, too…

Blossoming

  

It was Children’s Day at church and my kids were supposed to stand up and speak in front of everyone, something they had never done before.

I was absolutely terrified. I have stood down angry, threatening patients on multiple occasions. That fear is nothing like this fear.

These were my kids. How well they do is a reflection on me, right? I made it my mission to make sure they would not let me down…

We practiced like crazy. 

They knew their speeches/verses backwards and forwards. We drilled and recited over and over again until they were absolutely sick of it and sick of me. We only had a weeks notice so you can imagine how much work went into those seven days.

I had dreams of a flawless performance. I would stand at the back of the auditorium and receive the accolades of the admiring masses as the service let out. Yes, yes those are my children. Yes, they are very smart, aren’t they?….

This would be my shining moment of motherhood!

But when they stood up at their turns, they froze.

Perhaps I was too wrapped up in my own anxiety over this to recognize their own nerves? Maybe I enhanced their stage fright by my obsessive drilling? Maybe it was just bound to happen no matter what?

My son, wide eyed, lifted his shirt and grabbed his crotch, zipping his fly up and down, up and down. My daughter at her turn just stared. And stared. And stared.

Awkward silence reigned until the children’s minister stood up and helped prompt them through it, each in turn.

I just wanted to melt into my seat. 

Tons of kind people came up after to tell them what a great job they did, how it took tremendous courage just to mount the steps to the dais. And they were right. I should have been proud. This was not failure, not for them and certainly not for me. I felt shamed as I pondered all of this on the drive home.

As a physician I am constantly plagued by the sense that everyone is judging me on a different level than they might judge someone else. It doesn’t matter if they really do. It is what my mind tells me that matters in this case. Sometimes I can see past that and focus on my kids instead of putting on a show, but I will be honest with you, it is a struggle. Speaking at church was not about me, it should not have been about me, but I made it about me anyway. 

Practice

That is what motherhood is about. Practice. Just like medicine. You try your darnedest to get it right, apologize when you don’t, and then work hard to do better the next time.

So to my kids, I love you both. Please forgive me when I am not perfect. I will love you always, flaws and all.

Carried Away

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For Cinco de Mayo I am going to tell you a story about my first margarita on the rocks…

In medical school I was assigned to the biggest, baddest, meanest resident in existence for my surgery rotation. He had made grown men cry more than once. 

I knew I was screwed.

The other student assigned to this resident was a fellow classmate who was known for smoking tons of weed. I think he is practicing pain management in Colorado now…

At any rate, as the med students assigned to this rotation we were lackeys, doing scut work that no one else wanted to do themselves.

Do what you are told, don’t draw attention to yourself. Stay out of the way. Learn as much as you can.

As it turned out, it was this resident’s last month at the program. He would be leaving for the biggest, baddest trauma surgery program in the country. The perfect match, in my opinion. He had a research project he had to wrap up before he left, however, looking at the use of hyperbaric oxygen in traumatic brain injury. 

You cannot go around bonking people on the head and then dissecting their brains in the name of science, so he was doing the research on rats. He had made a “machine” with a hammer that was supposed to generate a consistent amount of force when it whacked the rats in the head. No matter how many variables you try to control, closed head injuries are still variable. Highly variable. So you have to have a sufficient number of victims to account for that variability.

We spent the month scrubbing in on surgeries and getting yelled at by this guy, but he also made it clear that we had to help him with the rat project. So we anesthetized dozens of rats, bonked them on the head with the hammer machine, treated them with hyperbarics, then euthanized them and harvested their brains. 

I hated every single last minute of it. If there is a hell and I end up there, I imagine there will be an army of rats waiting to eat my face off.

On the last day of the rotation, as I cut out the last brain of the last rat, this scary as hell resident congratulated us on surviving and told us we were the best students he had ever taught. He wanted to take us out for a drink.

So he did.

Now, I had never really been an alcohol drinker. In fact, I had to that point in my life only ever had a single frozen margarita. It had tasted good. When I was asked what I wanted to drink, I picked a margarita thinking I would get one of those nice, delicious, fluffy frozen ones.

“Do you want that on the rocks?”

I did not know what the hell that meant. So I said yes. 

“Give her extra tequila,” my pot smoking friend said. The waiter laughed. My friend laughed. The surgery resident from hell laughed.

That was about 7PM.

By 7:30PM, when I stood to walk out, the world was listing to the left.