On the Edge

I was deeply affected by a blog I recently read, written by Dr. Elizabeth Breuer, for KevinMD (here), regarding a comment made to her by an attending on a stressful night. It must have been a difficult experience for her, struggling to effectively care for her patients, while the negative label adhered to her psyche like a name tag. It's very unfortunate that the attending didn't catch herself...had she forgotten what it was like to be a stressed yet diligent resident? What if Dr. Breuer didn't have a support system or a blog to provide an outlet?

Dr. Breuer's experience is not limited to night float obstetrics. How many times have you been affected by a fleeting, yet hurtful remark? The "sticks and stones" adage may be a nice sentiment, but is unrealistic. As social creatures, humans are affected by what is said to us. We thrive on feedback, and it penetrates into the soul. When that soul is tired, grieving, stressed, wounded, or weak, words may be the fatal bullet. 


You never know what may be going on in someone's life. The grocery store checker may have just lost her mother. The doctor may have a special needs child. The student may be the victim of domestic abuse. The police officer may have just received a cancer diagnosis. When people appear to be competent and put together, we may trust the facade, and lash out nonchalantly. We may scan briefly for signs of trouble, and proceed with snide comments.

The problem? People in crisis often conceal their pain. Tears have a stigma of weakness, a manipulation, a "secret weapon" to garner favors. To protect ourselves, we don suits of armor, put on our best poker faces, and hide the crumbling foundation within. We overcompensate with strength…and it works, until that one final push. 

It could be a flippant remark from a co-worker. It could be a "dressing down" by a superior. It could be an angry tirade from a parent. It may even be a less personal action- closing the elevator in someones face, cutting them off, stealing a cab, etc. Cyberbullying suicides rarely occur after 1 incident. It takes repeated harassment, with the constant suppression of emotion, to nudge a victim to consider escape, until that final step. Will your poorly chosen words push someone over the edge?

Please, be kind. You just never know.

Identity

My first hospital job was in an OR recovery room. I was more of a switchboard operator than anything else...communicating with the OR and hospital floors- finding beds for patients, coordinating with ambulatory care for discharges, and keeping staff abreast of OR scheduling status. The calls would come in from the OR in the morning: "there's a hip coming in at 800am, after that we've got a lap chole". I envisioned a disembodied knee crawling down the hallway, followed by a hopping gallbladder. How would patients feel, knowing their hospital existence was reduced to their conditions? Or...maybe it's self-inflicted....

There have been plenty of JAMA and NEJM articles regarding the depersonalization of patients, the reduction of humans into disease conditions, but I have yet to read an article detailing how self-labeling impacts health. It always amuses me when a man introduces himself to me, and right away discloses that he has "ADHD". I usually retort, "Does that mean you can't take me to dinner?"

I hold the firm belief that everyone has or will have some medical issue, be it mental, physical, social, or otherwise. Does a disease define the person? Does the person define the course of disease? Does identifying oneself as a sufferer of a disease hinder the recovery, because that becomes their sole identity? Would a cure or remission deprive one of their identity? Would you be the same person if you were in complete health and free of disease?

I am not the panic disorder. I do not hug the brain injured in the morning, go to school with the depressed,  meet for lunch with the diabetic, and work out with the bowel disease. I do not call the stenotic valve and the prostate cancer on holidays, and send a gift to the preemie. The disease shouldn't define us...it should simply be an aspect, a facet to the many sides of a complex personality and a lifetime of memories. It should add richness to life, a chance to learn, teach, and be a catalyst for others' learning. I was told that Navajo weavers are sure to include a tiny defect in their rugs, acknowledging the imperfections and mistakes in life, and recognizing the beauty despite it, and within it. The mistake is not the totality of the rug, nor is it diminished into obscurity. It is celebrated for what it is. 

Memoratus in Aeternum

Mid-October has been a special time for me, since 2002. I am currently on the verge of sitting for my first "Step" in licensure, and felt it prudent to reflect upon how I arrived at a career in medicine. 

The year 2002 started off normally for my family, a close-knit group of 4-mother, child, and grandparents. Of these, my grandfather seemed the healthiest, save for a few bouts of gout every year. He led a healthy lifestyle, getting frequent exercise with his shepherd/husky mix, chopping trees, shoveling snow and visiting neighbors. He would fatigue quickly, so made a habit of taking daily naps. In late January, my astute mother noticed his ankles were edematous, and made an appointment with his PCP. The PCP prescribed diuretics and advised to follow up.  Shortly thereafter, my grandfather mentioned a nagging pain in his left side. My mother asked for a CBC, which was never completed. My grandfather was tested for heart failure, diabetes mellitus, and various other common ailments. Trips were made back and forth from the doctor; finally a CBC/peripheral blood smear was done, and a diagnosis was made- Chronic Myelomonocytic Leukemia; an extremely rare leukemia with no cure, and no detectability until the "crisis" stage, though commonly associated with chronic gout and splenomegaly.

My grandfather was referred to an oncologist, and began getting blood transfusions. He was put on a few blood-boosting medications and full-time oxygen. He tried to lead life as normal, continuing to cut branches and untangling the dog from the snarls of the oxygen tubing. When he felt well enough, he attended my dance performances, and we even went to see Mel Gibson's "Signs", although he was embarrassed to tote the heavy oxygen canister though the theater. I accompanied him to his blood transfusions, taking careful mental notes of the nurses too busy with birthday celebrations to notice that his oxygen canister was empty and rattling, or too engrossed in watching "The Price is Right" to remove his automatic blood pressure cuff after discontinuing his IV. I watched my strong, 6'3", 230lb grandfather slowly waste away, while trying to maintain normalcy in our lives.

The entire family worked hard to help him heal. In an effort to limit his fluid retention, we cooked low-sodium, low-fat foods, which were labeled and charted to ensure he was getting enough nutrition without harm. My mother purchased a CraftMatic bed for him, so he would be more comfortable and wouldn't use his precious energy trying to sit up in bed. He listened to self-hypnosis tapes and meditated daily, to focus his energy on healing and controlling proliferation. His oncologist seemed to be uncomfortable discussing his prognosis, and advised against splenectomy, due to my grandfather's insurance and age.

By the end of September, and with little encouragement from the oncologist, he decided that treatment was futile. "Save the blood for someone else," he said. "Someone who really needs it".  The oncologist offered to refer for splenectomy, but he was weary and resigned by this point. We discontinued the sodium and fat controlled foods, and made his favorites- lobster tail, hot dogs, shrimp. He passed away in his CraftMatic bed on Oct 17, 2002, missing his birthday by 6 days.

Every patient knows a story like this, either experienced personally or heard from others. Every doctor knows a hundred of these stories, shared in medical journals or by colleagues. Did a medical error occur? Patients and families may emphatically agree; Physicians may not feel the same. My point in writing is not to place blame, gripe about the state of healthcare, or lament that not enough was done to save my grandfather.  Perhaps the disease was caused by years of exposure to benzene from working in a pharmacy laboratory. Perhaps the cause was due to inhaled cigarette toxins, and he hadn't quit in time to prevent damage. Perhaps there is no attributable cause. Whatever the case may be, I believe that a plan is set out by the Most High, and for whatever reason, I needed to experience this loss, this suffering, in order to become a more observant, empathetic physician. I am so grateful for the time I spent with my grandfather, especially while he was most vulnerable. I am grateful for the lessons I learned through this process. When I approach the computer on Wednesday, I am confident that the spirit of my beloved grandfather will be with me. 

I love you and miss you, GVS. 

Take Your Time, Do It Right...

After watching the final moments of the Chilean mine rescue last night, I was impressed by the amount of patience exhibited by all involved with the ordeal. It took 69 long days to evaluate the situation, assess the most dire needs, and formulate a plan to keep the victims alive until the point of rescue. Once commenced, the rescue would have to be done slowly and safely, despite the anticipation of the crowds and media. What would have happened if the mine was exploded in a brazen effort to dig up the miners? Most certainly, the miners would have been buried forever. What would have happened if the rescue tube was yanked up expeditiously? The cable would snap, and the tube would plummet almost a half-mile back into the depths of the earth. Though not the quickest, last night's rescue will be remembered as the safest and most miraculous in history. 

What about patient rescues? Should all patient encounters be performed as quickly as an ER trauma or  life-flighted victim in shock?  As medical students, we are trained to perform physical exams in 15 minutes or less, pressured to elicit a detailed history in rapid-fire. A novice desperately auscultating for an ejection click or a bruit is unlikely to find it in the 3 minutes set aside for cardiac examination out of those 15. Patients are conveyor-belted through vital signs, insurance forms, physical exams, and deposited outside with a prescription in hand. Is this medicine? Or is it crowd control? 

I fear for the future of healthcare. I believe that Obama's healthcare changes will put more emphasis on efficiency rather than quality care. The shortage of healthcare professionals will be pressured to see more patients with less resources available, possibly missing crucial signs and symptoms. Can we still save lives with so little time to work? I can hardly imagine Hippocrates keeping an eye on a sundial as he examined a patient, or Osler advising his rounding medical students to speed up the patient's history because there were simply too many patients to visit. Physicians need time to process the data received, to think through the pathophysiology of the disease presentation. Occam's razor may apply in the majority of cases, but lives may be cost adhering strictly to it, and discounting other possibilities because the history is too long-winded, or because the diagnostic tests are too expensive. The speeding healthcare train must be slowed before it runs out of track. There should be no consequence for taking time to perform one's job properly.