Sewing Lessons

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“Come on sweetheart. Let the nice doctor take the stitches out!”

The four year old with dark curls was sobbing hysterically. Her mother was trying to soothe her. I was standing there awkwardly by the counter with the suture removal kit in hand…. still waiting.

“I can get some help with this….” I said quietly, trying to catch mom’s eye so I could mouth holding her down.

Mom shook her head no.

“I’ll buy you a toy if you let her,” Mom pleaded. “Anything you want…”

The kiddo pondered this. She held her arm out, warily. “Ok, ok. I’m ready.” 

She sniffed.

The wild look in her eye and the huge quantity of snot pouring from her nose told me otherwise.

I took one step forward with the forceps and little scissors and the sobbing and screaming started up again. We had tried this five times already. I was done, my patience worn thin.

I took a step back.

“How about if I leave and come back in a few minutes, let her calm down a bit?” I had three other patients already in rooms and two more still in the waiting room. I had already spent 30 minutes of a fifteen minute appointment (and they had shown up 12 minutes late to start with) explaining what I was going to do over and over again, even going so far as to let her hold and touch the scissors, all to no avail. 

“Yes, please!” Her mother sounded grateful.

Relieved, I left.

I knew from experience that with kiddos like this it was not going to work without restraining her. Once she realized after the first snip that this was going to be fine, she would relax and it would all be OK. It was clear that she had been tricked before. She knew not to trust adults, especially in this context. She was bound and determined that she was not going to be tricked again. She didn’t know me from Adam. All she knew was her past history. 

I couldn’t blame her.

I also knew that I could not do that restraining without parental permission. It was looking like I was not going to get that permission. 

Grumbling under my breath, I reviewed the next patient’s chart in the computer. I saw a couple of patients and then taking a deep breath, went back in.

“Are you ready to try again?” I smiled.

She nodded her head. Her puffy eyes and tear stained cheeks still said otherwise. Sure enough, as soon as I picked up the scissors, hysterics again ensued.

“Do you want me to get help?” I looked at mom. Please, please let me get help. She emphatically shook her head no, again.

“Sweetheart, do you want to come back again later?”she asked.

“Yes!” The water works stopped immediately and she hopped down off the table, smiling. She was at the door, hand on the knob, in half a second.

Of course she said yes.

I started assigning codes and printing the super bill. There was still going to have to be a charge for the visit. 

Her mother stared at me.

“She does not need those sutures left in indefinitely. That will increase scarring. Try to schedule in the next day or two…”

Her mother opened her mouth but hesitated like she wanted to say something.

“You want me to go ahead and grab some help?” I asked for her.

“Yes, can you? I really don’t want to pay another copay or spend another hour or two here again. Let’s just get it over with.” 

So I did. 

There was ear splitting screaming and that munchkin fought like a well trained ninja initially but she relaxed after the first suture was removed and stopped crying by the third. She was holding her hand out by herself for the last three. 

When we were done, she beamed proudly at what she had accomplished and literally skipped down the hall and out of the clinic afterwards, curls bouncing, chattering away happily, no worse for the wear.

It is terribly difficult for me to remember this with my own kids, that letting them experience something scary and overcoming it makes them stronger and happier and less anxious later in life. 

“Mommy I can DO it!” my son said as he started across by himself. All of the what if’s flew through my mind and my hand reached automatically for his. He swatted me away. “Let me do it!” He took one careful step after the other with me trailing close behind, but still letting him do it on his own, growing more confident with each movement forward, each step away from me.

Practice. That is what it is. Practice. And we all need it, early and often, though not necessarily in stitches…

Mooned

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I have several posts that I am working on right now but nothing that was “ready” because I spent the past couple of nights playing with my telescope until the wee hours of the morning. I am in possession of the proper adapters to attach my Canon SLR to my late 1970’s Celestron C8 Schmidt-Cassegran telescope but never could get it to take a good picture. I will have to play around with it some more.

What you see above is taken with my iPhone 4 through the telescope. You just stick the phone’s camera lens right up onto the telescope eyepiece. Did you know you could DO that? Me either. God bless the internet! It may not be the absolute best photo of the moon I have ever seen but it is MINE.

I feel compelled to say a few words here about mosquitoes at night. I assume they were mosquitoes. I couldn’t actually see them. It was dark. Go figure. Whatever those blood sucking bastards were, they laugh in the face of DEET and managed to turn my legs into something that resembles the craters of the moon’s surface. I will NOT be wearing skirts to work this week. Sob.

Speaking of insects, I have been exceedingly frustrated with several of the new bugs in Word Press (such as not activating the like or share buttons for posts generated or updated from the phone app). I blog mobile. It is what I do. It is the only way I can do what I do. Unless this bug gets fixed I am not sure what the future holds for me as far as blogging is concerned.

So, I am going to try scheduling this post from my home computer. If you see it at noonish today, then WOOHOO! It worked. I generally don’t have good luck with this scheduling stuff so if you see it 6AM you can go ahead and laugh at me.  I deserve it.

The Sick Child vs Modern Medicine

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To a parent, there is nothing worse than having a sick child. The normal colds and childhood diseases are stressful enough, but a chronically ill child is more than many people can handle.

In hindsight, I can explain all the little incidences that cropped up during Cordelia’s childhood. But at the time, I depended on modern medicine to tell me what was wrong, and modern medicine failed. Let’s see if you can figure it out before you get to the end of our story:

I think Cordelia was about 4 when the first notable incident occurred. Hubby and I were both working that day, and Cordelia was cared for by her grandparents. When I arrived that evening, Grandma greeted me by saying, “Let me tell you what we did.” I assumed she was going to tell me they went to the movies, or shopping, or some such – imagine how shocked I was when told that Grandpa had realized his heart medication was running low and needed a refill, so he emptied the bottle into an ordinary drinking glass, which he then put into the kitchen cupboard. Cordelia asked Grandma for some milk. Grandma grabbed the first available glass. Yes, you guessed it – Cordelia ingested Grandpa’s heart medication.

Fortunately, this happened not too long before my arrival, because no one had thought to call a doctor. I called Poison Control, which resulted in Grandpa driving around to several local pharmacies looking for ipecac – wouldn’t you think that would be kept in stock? The ipecac was administered, and the vomiting began. All normal thus far – except that Cordelia could not stop vomiting. We sat her in the tub with a bowl. I called Poison Control, who advised to just give it time. It took hours, but eventually the vomiting stopped.

I don’t know if that incident was the cause of all that followed, or whether it was merely an indication that there was an underlying condition that should have been attended to.

When Cordelia was 8, she got the flu. She could not stop vomiting. Being a stupid young mother, I let it go on for days and finally realized she was sleeping a lot. I thought that was good – she wasn’t vomiting while sleeping, right? I was too inexperienced to know that excessive sleeping after a bout of sickness could mean severe dehydration. When she slept through the evening and into the next morning and then woke up vomiting AGAIN, I called the doctor. This resulted in Cordelia’s first hospitalization. She was put on IV fluids and kept overnight.

After that, every time she became ill, she would experience uncontrolled vomiting, and each time she had to be admitted to the hospital. A normal case of chicken pox resulted in her being quarantined in a hospital room for several days. I’ll never forget the poor father who saw me step out of the doorway marked “QUARANTINE” and grabbed his child away from me for fear she would contract some horrible incurable disease. I tried to explain it was just chickenpox but he didn’t believe me.

The hospitalizations became more frequent and lasted longer. She was getting sick every couple of weeks. I kept an overnight bag packed at all times. At one point, Cordelia got sick and I called the doctor, apologizing. I said I didn’t want him to think I was an overly protective mother who called every time her kid got a little bug. His response was, “In her case, I think you should call.”

It was so bad that when Cordelia started vomiting, her younger sister started crying – because she knew Mom would be going away with Cordelia for a couple of days.
And the absolute worst was the day I had Cordelia in the tub, washing her prior to taking her to the hospital. She looked like a starving child from Biafra, and her skin was so hot that when I touched her, I felt repelled – immediately followed by “This is my child, my baby – how could I feel that way? What kind of mother am I?”

As the course of Cordelia’s illness continued, I began to doubt my abilities as a mother. How could a child become ill so often? What was I doing wrong? It didn’t help that one of the pediatric nurses accused me of Munchhausen by Proxy Syndrome. I had to look it up, at which point I began to doubt my own sanity. Was it possible that I was somehow deliberately making my own child sick just to get attention from medical personnel? Could I be doing something so horrible without knowing it?

Tests were done – xrays, ultrasounds, MRIs and an EEG (I insisted on being in the room for the EEG – Cordelia slept through it, but the strobe lights nearly made me throw up). A psych consult was ordered (for Cordelia, not me, and it came out normal.)

Cordelia’s vomit began to show flecks of blood. The doctors said not to worry.
During her 11th hospitalization (Cordelia was 10), she suddenly started vomiting fresh blood. The floor resident had to lavage her – twice (pump water into her stomach and wait for it to come back up clear – I can’t imagine what that must have felt like).

The next morning, our regular pediatrician arrived for rounds, and I totally lost it. The poor man stood silently for at least 10 minutes while I ranted about the inadequacy of Cordelia’s care, ending with, “That blood has to be coming from somewhere!” The pediatrician put his head down, and then responded, “You’re right, and we’re going to get to the bottom of this.”

Finally, a GI consult was ordered. The GI doctor arrived with an attitude – he couldn’t believe he had been called in simply because a kid was throwing up. As he entered the room, Cordelia held up both hands, with the fingers flexed backwards. I sighed and said, “She swears she’s not doing that.” The GI doctor’s attitude did a 360 degree turn, as he replied, “She’s not, she’s throwing potassium.”

An endoscopy was performed, and afterwards, the GI doctor had me escorted right into the procedure room, where Cordelia was still lying unconscious on the table. The doctor was at a computer, and had pictures to show me. Cordelia had several ulcers in her esophagus, which in the doctor’s opinion were “very, very bad.” Aggressive treatment was to start immediately, consisting of Zantac, Reglan and Prilosec.

Later that evening, Cordelia began to hallucinate, and I called the nurse in. It turned out that the floor resident had miscalculated the dosage of one of Cordelia’s medications, and had prescribed 10 times the amount she was supposed to get! Fortunately, there was no apparent damage caused by the error.

Cordelia began to heal, and that GI doctor became my favorite person in the whole world.

Was the ordeal over? Not quite yet. There were a couple of subsequent hospitalizations, but essentially she continued to improve. The school nurse was a saint who managed to keep the medication schedule (each drug was to be given at a different time).

So, what was the final diagnosis? Have you guessed it?

Gastroesophageal reflux disease (GERD)

These days, we all know what it is, if only from all those TV ads for Zantac and Prilosec. Back then, I’m not sure that Prilosec was even recommended for pediatric use.

Why did I not see the signs? Too many of Cordelia’s vomiting episodes seemed to start after her favorite meal of spaghetti, juice and chocolate cake. Or, did it all start way back when she accidentally drank Grandpa’s heart medicine? We’ll never know for sure.

I’m just glad that the nightmare ended. God bless those parents with an ill child for whom the nightmare never ends. No one should have to go through that.
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This was a guest post by Cordelia’s Mom. If you have not checked out her bog at Cordelia’s Mom, Still please do! She is one of the bloggers I have looked up to since I started blogging. I am honored she took the time to share this post over here.

Charmed, I’m Sure…

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My planned day off was highjacked by a sick little girl yet again. You know how it goes: high fevers, almost no sleep, glassy eyes (hers and mine but for different reasons), fetid strep breath, unhealthy levels of gooey snot boogers…

Best of all?

Puke.

Her puke in my hair and on my pillow because, you know, I let her sleep with me last night.

Sigh.

So, instead of that quiet house, bottle of wine, and book that I was planning on, I am cuddling my princess, dressed in our matching ball gowns and tiaras. Even sick girls want to look pretty while watching Cinderella for the third time. Or is it the fourth time? I have lost track.

“He is a very handsome prince, mommy…”

“Someday you will find your own handsome prince, sweetheart.”

“But I don’t want to! I don’t want to marry him or anyone!”

“You don’t have to marry him…”

But… maybe someday…

Someday you will find the one who fits you like a glass slipper, baby girl. He will make you feel beautiful and special. He will love you as much as you love him and you will live happily ever after with no regrets.

Or something like that…

I hope he doesn’t mind puke.

Thatched

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There are certain chores that annoy the hell out of me:

Putting gas into my car.
Washing makeup off my face.
Applying cosmetics.
Washing dishes.
Vacuuming.
Folding laundry.
Shaving the bikini area.
Trimming fingernails.

They are necessary, to be sure, but they are tedious. Mind-numbingly tedious. 

Sooooooo…. I am curious. What chores do you loath? 

The Power of Love

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When I was in training there was a woman who for many years taught every single resident to come through that program how to treat congestive heart failure.

She was the classic definition of a frequent flyer. She lived alone in a ramshackle motel on the outskirts of town. She had kids but they didn’t like her and never came around. I can’t say that we blamed them. She was mean as hell.

Each time, she would stop taking her meds and her body would swell …legs like giant sausages, lungs frothing, drowning in the excess fluids. You could see on her face that she was suffering and it was hard to understand why she did this to herself time and again.

Just take your frickin’ meds already!

We would admit her, give her IV Lasix, make her pee liters and liters over 3-4 days, and then send her on her way knowing full well that she would be back again in two or three weeks.

One late night, it was my turn. She had a reputation for being an ugly, hateful woman and I did my best to walk in with a Code Red swagger, guns blazing. This tactic worked for a lot of difficult patients… but not for her. Before I had completed my interview for her history and physical she was spitting and cussing and screaming at me to get the f**k out of her ER room. 

(In all fairness, that room had probably had been purchased for her by all of those previous visits so she was well within her rights…)

I decided to let her cool off and try again in a few hours before morning rounds. 

When I went back I decided I would try the sweet, perky lady doctor routine. When I bounced into the room she cracked one eye open at my cheerful greeting and grunted.

“I remember you,” she growled, told me to go to hell, then rolled over in bed with a few more loud grunts so that her back was to me.

“Look, you know the routine. This isn’t your first rodeo. I have to do this, so let’s just get it over with shall we?” 

I did a cursory exam as she riddled off expletives at me. She was a professional abuser and before it was over with, I was fuming.

I had let her get to me.

As we did rounds with the attending, she was sitting up with her bloated legs hanging over the edge of the hospital bed. She lit into me again, telling anyone who would listen that I had cussed at her (I might have) and had manhandled her (that part probably wasn’t true).

Finally, I had had enough. I let everyone go on ahead of me and I sat on the edge of the bed next to her.

“What do you want?” I asked her, struggling to keep the frustration out of my voice.

“Something you can’t give me.”

Was that a tear? My stony heart softened ever so slightly.

“Try my?”

She stared warily at me for a minute, sizing me up. Finally, she spoke. “I want someone to love me.”

I swallowed my pride. I put my arm around that woman and I told her that I loved her. Then, I told her that she needed a shower in a bad, bad way. 

She laughed. I laughed.

And that was the last we saw of her in the hospital. 

No joke. 

I saw her in the clinic every few months. She took her meds faithfully. She was not hospitalized again until 18 months later when she died of something completely unrelated to the heart failure.

She became one of my favorite patients and I miss her even now. She taught me that love, not swagger, gets things done. 

Trust Issues

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“Doc! His wife is on the phone, screaming obscenities, and says wants to talk to you. Apparently he tried killing himself last night.”

Oh, no…

I was wary. 

She was not my patient. They were in the midst of a bitter, ultra nasty divorce. I could not share information with her. Why was she calling? 

There had to be an ulterior motive.

“Please find out what she wants.” I did not want to talk to the woman if I could avoid it.

A few minutes passed while I worked on other patient medication refills. Eventually the secretary stuck her head into my office.

“Uh, doc? She says she is going to sue you for malpractice.” My heart started pounding.

“Really? Why?”

“She says you are responsible for her husband’s attempted suicide because of the medication you prescribed….”

Right. 

And the accusations, since dismissed by the court, that he was molesting the children had nothing to so with it? The revelation that she had had sex with other men repeatedly in the bed she shared with him did not affect him one iota? And the newest allegations of marital rape held no sway over his state of mind?

His life was falling apart when he came to see me. He was at risk of losing his job, his kids, everything. I had known him for a couple of years, watched him get married and become a wonderful young man and father. He was broken that day. He sobbed, begging me to help him.

We picked an SSRI. I don’t remember if it was Paxil or something else.

At the time I told him that he had to also start counseling and he would have to return to see me in two weeks time. 

Now this.

I sat in my office knowing I had done the best that I could but not being able to shake the feeling of guilt, nonetheless. Was it the drug? Did I do something wrong? 

He survived but he was not the only one with this story. I saw it with other drugs in this class. It has since become a well established fact that these medications cause an increased risk of suicide in teenagers and young adults.

Then, this article came out last week in the Atlantic. The data from a 2001 clinical trial paid for by Glaxo, the pharmaceutical company marketing the drug Paxil, was reexamined and showed that not only was Paxil not effective, it was not safe. The increased risk of suicide was hidden, labeling it as other less serious side effects.

Crossing Over

  
This new electronic health record?

It has been “optimized for a 24 inch screen”. You have to have a screen this size or you will waste 25 minutes per day doing extra scrolling and clicking. 

Or so they say…

A screen that size is not portable. We will have to have a computer in each room. Of course. Plus each physician will need a docking station in their office for their laptop.

This clinic that we are trapped in until 2018 has tiny rooms. It works carrying a laptop. I balance it on my lap while sitting on my wheelie stool facing the patient so I can maintain as much eye contact as possible. I try to type while we talk to maximize charting time and to ensure accuracy.

To have a computer in each room, given the room size and layouts, will require mounting it to an arm and using it with my back to the patient. That set up will cost about $3,000 per room. Each physician uses three rooms.

Paying for this will require seeing seven more patients per physician per month for three years at which time the computer equipment is obsolete and will have to be replaced.

Which begs the question, how do you do that with an already full schedule?!?!!!? 

Furthermore, why couldn’t this EHR have been “optimized” for a screen size that is more practical and portable? If this is the top of the line program, why wouldn’t they want portability? Who gets a cut of the equipment sales?

Lady-Doc Lunches

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I work with two other female physicians. I am sooooo grateful to have them around but there are days I may never see or speak to them, even though we work every single day under the same roof. 

What’s worse is we get so wrapped up in taking care of other people we forget to take care of ourselves.

So we started a few months ago reserving a time once a month to go have lunch together. We block our schedules so we don’t feel rushed to go back and see patients and do our best to ensure no other meetings impose themselves on our time.

We talk about the office. We talk about our lives away from the office. We eat tacos and queso fundido and chips and salsa… And we bitch.

It is incredibly helpful.

For years I have felt that even though I love the fall and winter as a season, this is the time of year that my job satisfaction plummets. I have started to feel it creeping in on me again this year ever since that first North wind blew in. This is when I start looking for new jobs or fantasizing about quitting medicine altogether…

I was starting to think that perhaps I have seasonal affective disorder, that maybe there is something wrong with me biochemically. Do I need to be medicated perhaps?

But, no! No, no, NO!

Yesterday one of the other lady-docs admitted she feels the same way each year and she has already felt it creeping in on her now, too. The volume of the clinic seems to correlate. More patients means more stress and means that the little things that don’t work right feel like mountains rather than mole hills.

It feels fantastic to find you are not alone. We may all be crazy but misery loves company.

So thank you, ladies. Thank you for helping me feel human. I love working (and lunching) with you both!