Friday, August 27, 2010

SCFE, suicides, crisis and happy endings...

My last afternoon at work before I left for a couple of days (to do a Board exam) was kind of heavy. A young lady (pre-teen) came in for evaluation of hip pain and a limp. As she told me the story and I noted that she was obese, I was almost sure of the diagnosis before I asked her to get onto the examination table. As she was doing that, her mother told me that she had SCFE at about that age. I stopped in my tracks. That was the diagnosis I had in mind and was afraid I would find. SCFE stands for Slipped Capital Femoral Epiphysis. It is where the head of the femur (thigh bone) slips off its neck slightly. If not corrected, it can lead to hip dislocation, loss of the femural head (due to necrosis) and some pretty severe disability. Unfortunately, the only way to correct it is surgery. Pins are placed in the head of the femur connecting it to the neck (of the femur). On x-ray, SCFE looks like a scoop of ice-cream slipping off the cone (kind of appropriate image for summer time). I got the x-ray. The diagnosis was confirmed. Most 12-something year olds do not know what SCFE is. Unfortunately, this one did and immediately began to cry "I don't want pins!" Evidently, she had seen mom's scars and heard the stories. My heart went out to her.

Later that afternoon, I got to see an older girl -- a 3o-something. The appointment schedule said 'depression' and in dispassionate computer print on my screen told me I had 20 minutes. Needless to say, a box of tissues was involved, a pelvic exam and screening for sexually transmitted diseases and definitely more than 20 minutes were needed and spent.

At the end of the day, I get to take them all home. Not literally, of course. Nevertheless, they come home with me. It's Friday night -- a couple of days later, and 10:30 pm. I'm sitting in the dark in front of a computer screen writing this blog entry because I'm still thinking about them.

This afternoon while driving to the DMV to get my license updated, I saw a patient of mine walking in town. Just last week, this macho 50-something biker had sat in my office and bawled like a baby. About a year ago, he came in with back and leg pain. In the course of working this up, we diagnosed him with prostate cancer. He underwent a spiffy robotic surgical procedure to remove the cancer (and most of the prostate). Everything went well in that he has no cancer. The collateral damage is not so good. He lost the ability to have an erection. For a month, he was loaned a pump device that enabled him to get an erection. The pump had to be returned since it was a trial and he could not afford it. The reason he was crying in my office was that his fiance of 4 years was leaving him. There was some infidelity involved (it was not him) and she did not want to continue with someone who could not...well you know. He wanted to kill himself. He wished he had never had the surgery. Oh, and he still has leg pain. Ah, the wonders of modern medicine, no?

Okay. It's not all depressing. I don't know why, but the sad cases stay with me longer than the happy ones. Maybe it's my personality type. Maybe most people come to the doctor when something is wrong, not when things are going well.

It's summer time and was the last week of summer vacation (alas, for the school kids, not me). I've had a lot of kids in here for their sports physicals and 'back to school' exams. I enjoyed seeing lots of happy kids with stories of adventures and vacations during summer. Some have scars, scrapes, and tans to prove it too.

Several of my co-workers from my residency days have had babies and picked me to be their baby's doctor. I feel like a chosen godfather, an unofficial grandfather, a surrogate dad and big brother all in one. I've kept my professional demeanor (well, sort of) but I'd rather leap out of the white coat, hug them and then dance across the hall with their newborn craddled in my arms. Okay, so I can't do that on the outside. But hey, I'm dancing on the inside and no one can stop that. Of course, nervous nellie that I am, I examine these babies carefully. I listen to every historical detail the parents offer. I don't what to miss anything bad but I don't want to find anything bad either. Truth be told though, if there's something to be found or diagnosed or treated, I'd rather it be me doing that that someone else. That's why I do this. Those are my babies too!

Okay, good night!

Saturday, August 07, 2010


I don't know why, but for the last few nights I have been dreaming I'm at work -- either at the hospital or the clinic. Last night I had a nightmare. I was in a small ER somewhere and my patient was a 1 month old baby that was not doing well. I was doing a spinal tap and the CSF (cerebrospinal fluid) was turbid like dishwater. This child had bacterial meningitis and was dying! I began barking out orders and trying to get this child to the intensive care unit in Marshfield. It was chaos and a race against time.

The situation changed and I was on Isla Bastimentos in Panama, back among the Ngobe. This time I was tapping an older infant with improvised equipment in a barebones clinic and getting the same dishwater CSF. I began to cry because children were dying on meningitis and I could not save them. I managed to save 6 kids by giving them antibiotics in time, but one kid died. We did not have enough ceftriaxone, we did not have enough spinal tap kits or needles or syringes or IV start kits. I woke up crying. It is really hard to know what to do and watch helplessly as a patient dies because you do not have the tools you need. Wow, it took me quite a while to shake that off. It was so vivid. Brrrrrr!

Friday, August 06, 2010

The weeks

My practice is growing. I know have about 1100 patients that call me their doctor. Most days, clinic is a whirlwind of patient visits, emails, phone calls, and reviewing labs, imaging studies and reviewing nurses' notes and consults.

Last week, one of my patients called to say that she had felt a lump in her breast that was not there when I saw her for a physical in November. Her insurance was not going to cover an office visit, so she requested if I could just order the mammogram. I did. A mass was discovered in her right breast and a sample biopsied. The result: invasive lobular carcinoma. I called her to give her the results. She would not answer the phone or speak. Instead, her husband was to receive the bad news. I hate this part of my job -- giving bad news. Actually, I don't hate that part. I want to be there for my patients. It's the bad news part I hate. Every diagnosis weighs heavily on both my patient and me -- some like cancer more so than others. Sometimes though, a diagnosis is a relief. I got to call a patient who for years had been suffering with pain in the upper and lower abdomen. He was so frustrated that no-one knew what it was. This week, we finally found out: epiploic appendigitis. It may be chronic or it may respond to treatment, but for the moment, we both savored the pleasure of the end of one journey -- the 'what's wrong with me?' part, before embarking on the 'how do we fix it?' part.

I also got to diagnose hemachromatosis for the first time. This is a disease I had read about in textbooks but never actually seen. Making the diagnosis was like an 'aha' moment that suddenly pulled all of the symptoms the patient had, come together into a coherent picture.

The weeks are bitter-sweet: the treating of patients that get better, the diagnosing of patients who may or may not get better, depending on the diagnosis, the tearful goodbyes to patients who die, expectedly or unexpectedly and the cheerful hellos to the newborn babies born to my patients or as new additions to their families. They all run together in the same day, sometimes in the same afternoon. It is like a roller-coaster ride, emotionally, physically and mentally.

Most nights I arrive home spent. These days I dream of the clinic and the hospital. Some mornings I wake up feeling like it's not fair -- I feel like I just worked all night. Still, I am tired but happy.

I still got to say: this is so cool! Thank you Lord, for the privilege of seeing patients and practicing medicine!

Death and Birth

The pager vibrated where it sat on my table next to my desk lamp. I was sipping coffee at 5:00 am when I picked it up to see who was paging me. I was on call that weekend and it was a Sunday morning. The message was the one we never like to see: pediatric code blue, ER 15 minutes. I dressed hastily and got to the ER as fast as I could. Although I was on call, I was not on call as as a first responder. That job fell to the pediatric intensivist and residents on call. I went anyway. By the time I got to the ER, they were already there and CPR was well into 10 minutes. The 4-month old baby was pale and lifeless, pupils fixed and dilated with no pulse and no respirations. The code ran about an hour before it was stopped. The coroner would be doing an autopsy because of the untimely death of this previously healthy baby. Apparently, the night before, the infant had been fussy so his parents brought him into their bed. Cause of death was most likely SIDS (Sudden Infant Death Syndrome).

As I walked out of the ER, I could not help but remember the last time something happened, that I was a part of. It was during my intern year and the code came at the end of a 30-hour call period. I remember coming back to my car numb and crying as I sat in the drivers seat, overwhelmed, tired, shocked and heartbroken.

This time, I got back in my car, drove home, showered and returned to the hospital to see newborns. I'm not an intern anymore. I can't say I feel nothing, but I was not as overwhelmed as I was the first time. That morning, my responsibilities included performing the newborn exam on all the babies that had been born overnight. As I looked into their little faces, I could not help but smile while in my mind was the image of the dead baby I had seen only an hour or two ago. From death to birth in a morning. That is medicine.