Christmas is a time for joy...but not always. I was on call for pediatrics when my pager went off at 5:30 am in the morning. When I called back the nurse informed me that a kindergartner had passed away. I went in to declare her dead. She had fought cancer and lost. Her mother held her body in her arms and wept. Her father and grandparents stood around the bed. There are no words for times like this. I have had this family in my prayers during this holiday season.
Just a few days ago I had gotten notification that a patient of mine had died in hospice. I remembered the phone call from his aged wife a month ago asking me if I would prescribe home health because she could not no longer move him into a tub or onto a commode by herself. By herself! I remembered encouraging her to bring him in. He would not come. When he finally did, he died 2 days later. Once again, losing a life partner of many decades at a time like this must be crushing. When hollywood shows love, it shows beautiful young people, hands and eyes locked together. However, I see love in this elder woman trying to help her husband onto a commode or into a tub. He has nothing more to give her. She will get nothing in return. She does it just because she loves him. They have shared life, home, bed and children for decades.
My prayers go out to these families and other like them in need, sickness or alone.
Saturday, December 25, 2010
Sunday, December 12, 2010
Let it snow!
Aaah! I finally have a weekend off when I am not working the ER, not staffing wards, not in Urgent Care or the newborn nursery. Actually, I was supposed to go to City on a Hill for the monthly free clinic, but the roads were too hazardous to make the three and half hour journey there and back. So I get to spend the weekend at home (could update the blog too :-) ).Since we have no place to go, let it snow, let it snow, let it snow....er... okay now, enough, please stop!
Been waiting too long?
It was around Halloween time. The clinic was very busy and a few unexpectedly complex cases had set me behind (can you sense me making excuses yet?). I must have been running about an hour behind schedule.
I walked into the exam room of my next scheduled patient and saw this! I came out as quickly as I could and got my medical assistant to come and look too. We all burst out laughing.
What do you think? Been waiting too long?
Practicing in Resource-Poor settings
At City on a Hill's monthly free clinic, one gets to practice medicine a little differently than at my usual place of work. For one thing, we do not have access to the same resources (labs, imaging, sub-specialties) that one has in a larger clinic, multi-specialty venue or hospital. And yet, patients may have problems that could benefit from this. I saw a woman with an obvious goiter. Interestingly, her mother had the same thing. They had lived their entire lives in the U.S. in a city. She had mixed symptoms of both hyper and hypothyroidism. Management is proving to be challenging. I chatted with an endocrinologist friend who is from India. He suggested some physical exam techniques and history I could obtain to help manage her without further expensive imaging. I benefited from his experience managing patients in a resource-poor setting.
Thursday, December 09, 2010
BRCA1
I love taking care of entire familes. It gives me the opportunity to know the pertinent medical history of not just the patient, but his or her relatives too. It introduces me to the support system (or failure thereof), the psychosocial environment and allows me to effect changes that benefit everyone in the home (like in diet, smoking habits and such). Sometimes though, while the opportunities to care for the whole family are beneficial, they are not joyful.
I have one such somewhat disjointed family in my practice. I take care of 3 generations of women -- a grandmother, her young daughter and that daughter's toddler. recently, grandmother -- a somewhat young lady in her mid-40s found a lump in her breast. We got the biopsy and it was positive for cancer. Because of her age, we checked her for the dreaded BRCA1 mutation. She was positive. This means that her daughter and grand-daughter are at increased risk too. Deleterious mutations in the BRCA1 gene may confer as much as an 87% risk of breast cancer and a 44% risk of ovarian cancer by age 70 in women (Lancet 343: 692-695, 1994). This also confers a 20% risk of a second breast cancer within 5 years of the first and a 10-fold increase in the risk of subsequent ovarian cancer. Her daughter and grand-daughter have a one-in-two chance of having this mutation
This is crushing news for these 3 generations of women. Recommendations go even as far as prophylactic bilateral mastectomies (removal of both breast completely to prevent developing breast cancer. The younger women will need yearly mammogram and/or breast MRIs from age 25 upwards.
I have one such somewhat disjointed family in my practice. I take care of 3 generations of women -- a grandmother, her young daughter and that daughter's toddler. recently, grandmother -- a somewhat young lady in her mid-40s found a lump in her breast. We got the biopsy and it was positive for cancer. Because of her age, we checked her for the dreaded BRCA1 mutation. She was positive. This means that her daughter and grand-daughter are at increased risk too. Deleterious mutations in the BRCA1 gene may confer as much as an 87% risk of breast cancer and a 44% risk of ovarian cancer by age 70 in women (Lancet 343: 692-695, 1994). This also confers a 20% risk of a second breast cancer within 5 years of the first and a 10-fold increase in the risk of subsequent ovarian cancer. Her daughter and grand-daughter have a one-in-two chance of having this mutation
This is crushing news for these 3 generations of women. Recommendations go even as far as prophylactic bilateral mastectomies (removal of both breast completely to prevent developing breast cancer. The younger women will need yearly mammogram and/or breast MRIs from age 25 upwards.
Sunday, September 26, 2010
Temporary Insanity
Life as a physician is busy. It would be wonderful to have a day to just read: textbooks, journal articles, look up stuff relating to perplexing cases, but that does not happen. It would be nice to come home not completely spent emotionally, physically and mentally and have a second wind to do something else. Not usually on a weekday.
The solution: temporary insanity.
Every so often, I get a complete weekend off -- no call, no volunteer work scheduled, no extra shifts, (we'll not talk about the piled up reading, studying for boards, doing CME activity, it'll be our little secret). This is not often, you understand.
That's when it happens: temporary insanity.
For 2 glorious days, I am not a doctor, not a scientist and sometimes, not even a sentient being. I eat. I sleep. I watch a nonsensical movie. I buy a comicbook or a science fiction mag. I vegetate. It's like a mini-vacation. It's pretending that there are no pending deadlines, it's supressing the perpetual guilt one feels for not studying enough, not reading enough, not being up to date with every last shred of paperwork, not having answered every last email, not having cleaned the bathtub in a while, or the kitchen, or ...never mind. Temporary insanity makes it all go away. It feels good. In the words of a country song I heard "I don't have to be me till Monday."
The solution: temporary insanity.
Every so often, I get a complete weekend off -- no call, no volunteer work scheduled, no extra shifts, (we'll not talk about the piled up reading, studying for boards, doing CME activity, it'll be our little secret). This is not often, you understand.
That's when it happens: temporary insanity.
For 2 glorious days, I am not a doctor, not a scientist and sometimes, not even a sentient being. I eat. I sleep. I watch a nonsensical movie. I buy a comicbook or a science fiction mag. I vegetate. It's like a mini-vacation. It's pretending that there are no pending deadlines, it's supressing the perpetual guilt one feels for not studying enough, not reading enough, not being up to date with every last shred of paperwork, not having answered every last email, not having cleaned the bathtub in a while, or the kitchen, or ...never mind. Temporary insanity makes it all go away. It feels good. In the words of a country song I heard "I don't have to be me till Monday."
20 minutes
What does 20 minutes to you? To me, during the work day, it is the length of time I have to spend with my patient who is here for anything but a complete physical. It doesn't matter: cough, cold, diarrhea, feeling suicidal, family crisis, swollen knee that needs fluid taken off, or discussing the test results that reveals a possible malignancy. I often joke about having to solve the world's problems in 20 minutes -- that is primary care. Of course, I exaggerate a little and jest a little, but only a little.
Er... did I mention, I usually run late and work through most lunches? You might wonder what the problem is: why can't we take more time with our patients? The answer is logistic, philosophic and economic and part mystery (to me, anyway). I understand but I don't understand. Ever been there?
One problem is advanced access: the number of days it takes to be able to see your doctor if you call, the first available appointment to establish care, or for follow up or for an acute problem. You could go to the ER or urgent care, but then, why have a doctor if you can never get in to see him or her when you need him/her? The other aspect is economic: primary care is reimbursed not for the amount of time you spent, but for the type of visit (office visit, often called an E & M [evaluation and management] visit) and the number of diagnosis made. These are paid at a much lower rate that a procedure of equivalent time by most payors (the government, insurance companies and such). Consequently, the only way to 'break even' (balance the cost of running a clinic that does primary care) is to see more patients in a given day.
Again, I don't understand it all. It sometimes seems like a factory (with terms like productivity, number of patients seen per unit time or in our world RVUs generated (RVU=revenue value units).
I try to spend as much time as the situation seems to require. I do not look at the clock or 'kick' a needy patient out because their 'time's up'. Consequently, as the day advances, I fall behind and my patients may get a bit flustered because they showed up on time for an appointment and find that they have to wait an extra 20 to 45 minutes.
By the way, there is no allocated time for phone calls, emails, pages, filling out forms or signing prescriptions to be called in. Those are squeezed in as you walk out of one room and before you walk into the next. You also need to document the visit (we dictate our clinical notes) and bill (to register the diagnosis).
Pause.
It's madness. It's a sisiphial task. It's frustrating. But, I LOVE what I do, I LOVE seeing patients and (hopefully on most days) making a difference and yes, sometimes, on a good day, I do solve the world's problems in the magical 20 minutes. :-)
Er... did I mention, I usually run late and work through most lunches? You might wonder what the problem is: why can't we take more time with our patients? The answer is logistic, philosophic and economic and part mystery (to me, anyway). I understand but I don't understand. Ever been there?
One problem is advanced access: the number of days it takes to be able to see your doctor if you call, the first available appointment to establish care, or for follow up or for an acute problem. You could go to the ER or urgent care, but then, why have a doctor if you can never get in to see him or her when you need him/her? The other aspect is economic: primary care is reimbursed not for the amount of time you spent, but for the type of visit (office visit, often called an E & M [evaluation and management] visit) and the number of diagnosis made. These are paid at a much lower rate that a procedure of equivalent time by most payors (the government, insurance companies and such). Consequently, the only way to 'break even' (balance the cost of running a clinic that does primary care) is to see more patients in a given day.
Again, I don't understand it all. It sometimes seems like a factory (with terms like productivity, number of patients seen per unit time or in our world RVUs generated (RVU=revenue value units).
I try to spend as much time as the situation seems to require. I do not look at the clock or 'kick' a needy patient out because their 'time's up'. Consequently, as the day advances, I fall behind and my patients may get a bit flustered because they showed up on time for an appointment and find that they have to wait an extra 20 to 45 minutes.
By the way, there is no allocated time for phone calls, emails, pages, filling out forms or signing prescriptions to be called in. Those are squeezed in as you walk out of one room and before you walk into the next. You also need to document the visit (we dictate our clinical notes) and bill (to register the diagnosis).
Pause.
It's madness. It's a sisiphial task. It's frustrating. But, I LOVE what I do, I LOVE seeing patients and (hopefully on most days) making a difference and yes, sometimes, on a good day, I do solve the world's problems in the magical 20 minutes. :-)
A mother's worst nightmare
The story has been heard before, but this is the first time I was part of it. I have a young adult girl and her family in my practice. On a Monday morning I got a phone call from her mother that she was raped over the weekend.
Stop here for a moment.
In the middle of a busy Monday morning rush of patients waiting in rooms to be seen, phone calls to be answers, the pager going off and my email inbox warning me that there were several unread messages, time stood still.
Her friend invited her to a party on a Saturday night and introduced her to a boy. One thing led to the next and there she was in the ER. She said 'no' but maybe too late? Although a young adult, she lives with her parents and has some issues with depression and some developmental delay. A rape kit was collected, although it was locked away because she did not want to press charges because "I don't want him to get into trouble". The next day however, she changed her mind and the wheels are set into motion.
We treated her for potential sexually transmitted disease exposure, tested her for pregnancy and set up an appointment for her counselor.
Running behind. My medical assistant reminds me that room 2 is a 1-month old baby boy here for a well child visit with his parents. I put my feelings in the ice box, put a smile on my face and walk in to a happy family.
Stop here for a moment.
In the middle of a busy Monday morning rush of patients waiting in rooms to be seen, phone calls to be answers, the pager going off and my email inbox warning me that there were several unread messages, time stood still.
Her friend invited her to a party on a Saturday night and introduced her to a boy. One thing led to the next and there she was in the ER. She said 'no' but maybe too late? Although a young adult, she lives with her parents and has some issues with depression and some developmental delay. A rape kit was collected, although it was locked away because she did not want to press charges because "I don't want him to get into trouble". The next day however, she changed her mind and the wheels are set into motion.
We treated her for potential sexually transmitted disease exposure, tested her for pregnancy and set up an appointment for her counselor.
Running behind. My medical assistant reminds me that room 2 is a 1-month old baby boy here for a well child visit with his parents. I put my feelings in the ice box, put a smile on my face and walk in to a happy family.
City on a Hill -- A free medical clinic
Every second Saturday of the month I try to go over to Milwaukee to work at the Free Medical Clinic. This is run by a missionary organization called City on a Hill (http://www.cityonahillmilwaukee.org/) that does wonderful work in inner city Milwaukee. The clinic is held every second Saturday of the month. It runs from noon till about 5 pm. Anyone can come. No money is charged. The photo alongside shows the last of several hundred poeple getting in on a Saturday afternoon in September 2010. Did I mention, there is a free lunch and an opportunity to take home a grocery bags of basic foods? 
Most medications are provided with the visit, free of charge. This is an amazing work. There are about 3-5 doctors who volunteer on a regular basis. We have a filing cabinet and each patient has a 'chart'. Vitals are taken by volunteer nurses. There are allied services such as free foot care, smoking cessation, flu shots (in the season) and occassionally optometry and physical therapy.
Diagnosis is an interesting experience. Labs and x-rays are very expensive and not available on site. Most diagnosis therefore relies heavily on history and physical exam (aren't we supposed to be able to diagnose most things that way? ;-) ). I have gotten to hear some interesting aortic stenosis murmurs, perform incision and drainage of a cyst, clean out a cerumen impacted ear using a syringe and an IV catheter and palpate some impressive goiters like this one.
In medical school, I was taught the biopsychosocial model of medicine. I believe in the biopsychosociospiritual model: illnesses can have a spiritual component as well. Poor choices or decisions in life, unforgiveness, bitterness, anxiety, guilt -- where else can you place these in the biopsychosocial model?
Working here once a month teaches me to appreciate what we have. The first time I went, I treated a homeless man for pneumonia and a family for scabies. I could not believe I was in one of major cities in the United States.
We sometimes have premeds and medical students come along and with the patient's permission shadow us while we work. We often have to write out our own labels for the prescriptions, count out the pills and fill the bottles ourselves and then explain the instructions to the patient. It gives one a sense of appreciation for other members of the medical team that we have back in our 'not-free' clinics -- receptionists, medical assistants, nurses and pharmacists to mention a few.
Perhaps the most touching aspect of the work is how grateful the patients are that we come. They say thank you again and again, as if we are the ones that are inconvenienced and suffering. I don't presume to know how to fix our broken healthcare system, but when I see out of work, homeless folk with diabetes, hypertension, skin conditions and other chronic medical problems who must make do with a once a month free clinic with a limited selection of drugs, I know I must do something. So I go.
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!
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
Nightmare
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!
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!
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.
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.
Sunday, July 18, 2010
Camp Angel Summer 2010
Wow, looking over this blog, I can see that I have not been writing much. This is not because nothing's happening. Rather, it is the opposite. I will try to do better. Well, July 9 through 11, I was at the summer Camp Angel. To learn more about Camp Angel, visit their website: http://www.angelonmyshoulder.org/cancer-support-programs/31-camp-angel/132-camp-angel-activities.html.
Like last year, this camp was held near Three Rivers in northern Wisconsin at Camp Luther (http://www.campluther.com/) . Camp Luther is a beautiful facility with several different kinds of camp buildings for the kids: a fort, a tower, an Ark and other wooden, fun architectures that make an adventure out of staying there.This year there were 24 children, an equal number of boys and girls. As with each year, they were divided into groups according to ages. The 8 and 9 year old girls were called the Bunnies, the 8 and 9 year old boys, the Bears, the 10 through 12 year old girls the Foxes and the 10 through 12 year old boys the Wolves. Each group had 2 to 3 counselors. Every year the groups do fun things with their names like 'the Foxy Ladies' and the boys shouting, "Who Rocks? THE BEARS!"
When the kids get off the bus, one tends to see... kids. But if one sits down and reads their application forms, one sees the heartbreaking stories behind them. One of the children lost his dad to cancer only in April. Others have lost a mom or grandparent. Others have a sibling with cancer. What does this do to a kid? We had one little girl on 2 sleeping pills, something to prevent her wetting her bed and something for acidity. Those of us administering the medications shook our heads in increduility and dismay even as this 8 year old pointed to each tablet and told us why she had to take it. A number of kids were on antacids, ADHD medication or something for chronic headaches. Processing the stress of a close family member with cancer can code in their little bodies as psychosomatic illnesses, behavioral problems or actual physical ailments.
One little girl got off the bus and was brought straight to me: "She threw up the whole way here!" She had a headache and did not feel good. I took her to the medical room and encouraged fluids.
That evening, we had a scavenger hunt with the kids having to find things like a bronze bowling pin, a particular kind of feather, eggs and other items skillfully hidden on the grounds by their counselors. As happens every year, the Northern Wisconsin Harley Davidson group drove in revving up their motors to make a grand entrance. The kids gazed wide-eyed at the shiny motorbikes. Several took pictures sitting on one or more of the bikes. I held onto one 11 year old who had just been dropped off by his parents. He didn't feel like being there and was teary eyed as his family drove away with the admonition: have fun!
The next day was our main day on camp. After a good breakfast, buses of us set out for Three Rivers and Duck Lake, where Captain Steven
and his son Steve-O had a pirate ship ready and waiting for us (http://www.eagleriverpirates.com/). Before that however, I made a quick trip into town to pick up some anti-nausea medication for a few kids who, it turned out, had motion sickness. I also stocked up on hydrocortisone for bug bites, Aloe with some lidocaine for bad sunburns and some children's peptobismol. During the pirate ship adventure, most of the kids had fun. Captain Steve showed us a bald eagle's nest with a couple of birds in it. With pirate songs playing in the background ("My name is Roger, and my favorite letter is 'ARRRRHH"), we blew bubbles, and colored white T-shirts with pirate-themed pictures. Counselors and myself looked out for kids that seemed to take themselves out of the fun because of depression or sickness and helped.In the afternoon after lunch which was a yummy cookout, we all got into the water. Kids jumped off the pier, swung on a rope for a splashy landing in the water, rode on tubes pulled by jet skis and motorboats and went fishing. We had a few sunburns, scrapes and and nausea but nothing major. I stayed in the water and helped kids on and off the tubes.
I smiled at one group of 3 8-year olds who had never been tubing and wanted to try it for the first time. As the motorboat pulled them across the lake, I could see the waves and wind cause the tube to skip and bob on the water, causing their little bodies to bounce, and they held on with two hands to little handles on the tubes. When the tube came to shore, their faces were white and eyes wide. They broke into smiles and pleaded "can we go again?" One little girl went 5 times.Kids took breaks to get their hair braided, face painted, play shuffleboard or paint souvenir rocks to take home.
After cleaning up, we gathered outdoors for DJ Dan and his music. We got almost everyone out on the floor to dance. It was a fun evening. After that, the campers went back to their camps for s'mores, a bonfire and whatever late night activities naughty campers do.
The next morning, after a breakfast, everyone got back on the bus to go home. There were lots of hugs, smiles and some sweet sadness of saying goodbyes.
Camp Angel is magic for these children. For a few days, they get to forget the solemnity of death, hospitals and sickness. They get to be kids. As a camp medical careprovider, I have learned to balance giving attention to illness, treating what needs treatment and otherwise distracting kids from their illness with some magical results. The camps have taught me that sometimes, distraction is much better than a pain reliever or stomach medicine and sometimes validation of a need is more important than treating it with something.
Kids are magic and seeing them have fun is rejuvenating for those of us adults who were there. I got my Camp Angel rock as a souvenir. Mine has a rocket ship on it. Well, I did have a blast!
Sunday, July 04, 2010
MUA - where I went to medical school
I get a fair amount of queries on Facebook and such about MUA -- the Medical University of the Americas and what my experience there was. Many inquirers want to know if the school is 'real' and whether they can succeed and get into residency in the United States or Canada after graduating from there. After writing individual replies (typed these days, painfully, on an iTouch) I decided it might be best to post this and send inquirers a link. I still try to reply with a personal message to each one, but so many people ask so many of the same questions, this just makes sense.
If memory serves me right, I joined MUA in January 2001. The school was (I think) in its second semester on the island. I had flown down to the island to visit several month before when the classrooms were still being constructed, the pool was a hole in the ground, the library building did not exist yet and there were no students. It was scary and I was not sure if I was doing the right thing.
I graduated from MUA in 2005 and began residency that same year. For the two and half years I was on Nevis, I bought took all my classes and taught biochemistry (this is why it took me a little longer to complete the Basic Sciences curriculum).
Okay, so here's the big picture... the things that really matter. MUA graduates have got into many different residency programs -- community to university-based programs in competitive specialties like neurosurgery, radiology emergency medicine, general surgery and practically every available type of residency program. Many were chief residents of their program in their final years. Many have gone on to do subspecialty training in fields like cardiology, endocrinology, nephrology, critical care, oncology and subspecialties in anesthesia like interventional pain management. This is only based on the people I know personally.
Bottom-line: the school delivers. We are proof of that.
Second-years have to do the United States Medical Licensing Exam Step1. There are 2 additional steps. I personlly know MUA students who have gotten in the 97 to 99 percentiles in these exams. These are very good scores.
Caribbean medical schools come in many shapes and sizes and degrees of credibility. I cannot authoritatively comment on any of them except the school I went to. In MUA's case, I can vouch for the school as a product of it who is a licensed physician in internal medicine and pediatrics and a clinical professor of these specialties with the University of Wisconsin.
Because the standards for getting into the schools in the Caribbean are not the same as those in the States, a number of students will get in that will never graduate. Some will never finish the Basic Sciences. Others will complete their time on the island but not pass the USMLE exam(s). Still others will graduate and never get into residency. I think this is because not everyone who gets into medical school is there for the right reasons. Some are there to please their parents and are trying to fulfill their ambitions. Others think that it would be really 'cool' to be a doctor, but have not sat down and counted the cost. Others have underestimated the sacrifice, hard work and years of training it takes to succeed.
Life as a caribbean medical school student is hard. Some people have a prejudice against caribean medical school students and graduates, thinking they are second-rate because they did not get into a U.S. (or Canadian) school. The interesting thing is that once you're in the hospital (third and fourth years), most people evaluate you by your performance and not your label. The Basic Sciences Dean at the time of my graduation from the island gave us this advice:
1. Be the first to arrive and the last to leave
2. Volunteer for everything ('who wants to look this up? Who want to try to start this IV?)
3. Own your patient (know their labs, their care plan, read on their diagnosis, evaluation and management).
I took this advice and did great. It was an honor to be a Chief Resident, to win an award for the Best resident teacher -- an award given by U.S. medical school graduates who were in training in my institute, and to be asked to join the faculty of our residency upon graduation from our program. I owe my school for these opportunities. MUA took me a student and gave me the instruction in the basic sciences, placed me in my third and fourth year clinicals, wrote my Dean's letter, gave me my degree and enabled me to get into residency and get licensed to practice medicine. What more can a school do?
The rest is up to you.
If memory serves me right, I joined MUA in January 2001. The school was (I think) in its second semester on the island. I had flown down to the island to visit several month before when the classrooms were still being constructed, the pool was a hole in the ground, the library building did not exist yet and there were no students. It was scary and I was not sure if I was doing the right thing.
I graduated from MUA in 2005 and began residency that same year. For the two and half years I was on Nevis, I bought took all my classes and taught biochemistry (this is why it took me a little longer to complete the Basic Sciences curriculum).
Okay, so here's the big picture... the things that really matter. MUA graduates have got into many different residency programs -- community to university-based programs in competitive specialties like neurosurgery, radiology emergency medicine, general surgery and practically every available type of residency program. Many were chief residents of their program in their final years. Many have gone on to do subspecialty training in fields like cardiology, endocrinology, nephrology, critical care, oncology and subspecialties in anesthesia like interventional pain management. This is only based on the people I know personally.
Bottom-line: the school delivers. We are proof of that.
Second-years have to do the United States Medical Licensing Exam Step1. There are 2 additional steps. I personlly know MUA students who have gotten in the 97 to 99 percentiles in these exams. These are very good scores.
Caribbean medical schools come in many shapes and sizes and degrees of credibility. I cannot authoritatively comment on any of them except the school I went to. In MUA's case, I can vouch for the school as a product of it who is a licensed physician in internal medicine and pediatrics and a clinical professor of these specialties with the University of Wisconsin.
Because the standards for getting into the schools in the Caribbean are not the same as those in the States, a number of students will get in that will never graduate. Some will never finish the Basic Sciences. Others will complete their time on the island but not pass the USMLE exam(s). Still others will graduate and never get into residency. I think this is because not everyone who gets into medical school is there for the right reasons. Some are there to please their parents and are trying to fulfill their ambitions. Others think that it would be really 'cool' to be a doctor, but have not sat down and counted the cost. Others have underestimated the sacrifice, hard work and years of training it takes to succeed.
Life as a caribbean medical school student is hard. Some people have a prejudice against caribean medical school students and graduates, thinking they are second-rate because they did not get into a U.S. (or Canadian) school. The interesting thing is that once you're in the hospital (third and fourth years), most people evaluate you by your performance and not your label. The Basic Sciences Dean at the time of my graduation from the island gave us this advice:
1. Be the first to arrive and the last to leave
2. Volunteer for everything ('who wants to look this up? Who want to try to start this IV?)
3. Own your patient (know their labs, their care plan, read on their diagnosis, evaluation and management).
I took this advice and did great. It was an honor to be a Chief Resident, to win an award for the Best resident teacher -- an award given by U.S. medical school graduates who were in training in my institute, and to be asked to join the faculty of our residency upon graduation from our program. I owe my school for these opportunities. MUA took me a student and gave me the instruction in the basic sciences, placed me in my third and fourth year clinicals, wrote my Dean's letter, gave me my degree and enabled me to get into residency and get licensed to practice medicine. What more can a school do?
The rest is up to you.
Saturday, May 01, 2010
Camp Angel, Winter 2010
This is WAY overdue...
I spent a weekend as the doc for Camp Angel (Jan 22 to 24, 2010). To those of you who don't know... this is a camp held for children whose families have been touched by cancer.
I spent a weekend as the doc for Camp Angel (Jan 22 to 24, 2010). To those of you who don't know... this is a camp held for children whose families have been touched by cancer.
It is one of several camps held by Angel On My Shoulder Non Profit Cancer Foundation. (Visit their web site at http://www.angelonmyshoulder.org/cancer-support-programs/31-camp-angel/132-camp-angel-activities.html to see reports on the camps and explore).
This year we had professional photographers, Lisa and Dennis Dewane (http://newdaephotography.com/) who took awesome photos.
Every year we get a sweatshirt or T-shirt, This year's winter came sweat shirt was in camoflauge to honor an old camp counselor, Sgt. Ryan Adams who died serving his country in October 2009.
We had a lot of fun and there were no medical problems. Loved it.
I encourage you to visit the Angel on My Shoulder web site and support this noble work if you can.
Friday, April 30, 2010
What a week!
Wow! It's the last day of April and I haven't written for so long...
One 'surprise' of being out of residency is that the 80-hour work-week ends. I was on call for Peds Thursday through Sunday. So I am so looking forward to this weekend off.
Last weekend I was on call and it was Prom weekend. Some teenage girl angst that I do not want to get into right now.
This may have been one of my worst weeks since starting in practice.
This week alone, I diagnosed 2 cases of breast cancer, one case of an atypical pre-cancerous breast mass, 2 new cases of diabetes and one unexpected prostate cancer.
I have done a lot of breast exams before this week, but I am changed in how I do them now. There is a pit at the bottom of my stomach when I am doing them now.
This 60-something gentleman came into my office for a physical (his wife made him come). He was on no medications and warned me that he did not want any tests. I talked him into a prostate screening test, and a diabetes screening test. He has prostate cancer and severe uncontrolled diabetes. I almost feel like I gave it to him and in a sense, I did. He was living his life without any labels and now he has two he did not want in the first place.
I've said this before. Medicine is a funny thing. In a day's schedule filled with 15 patients with 20 minutes per patient sometimes, you have to be able to go from one room where you said "I have bad news: you have prostate cancer" to a 2-month old well child exam where you get to say "He's doing great!" For me, it's when the day is over and I am spent, that it hits me.
I joke with my patients a lot. We try to keep the encounter light. I can't forget though, that this is serious business and under the veneer of the routine physical exam, cancer and death may lurk.
One 'surprise' of being out of residency is that the 80-hour work-week ends. I was on call for Peds Thursday through Sunday. So I am so looking forward to this weekend off.
Last weekend I was on call and it was Prom weekend. Some teenage girl angst that I do not want to get into right now.
This may have been one of my worst weeks since starting in practice.
This week alone, I diagnosed 2 cases of breast cancer, one case of an atypical pre-cancerous breast mass, 2 new cases of diabetes and one unexpected prostate cancer.
I have done a lot of breast exams before this week, but I am changed in how I do them now. There is a pit at the bottom of my stomach when I am doing them now.
This 60-something gentleman came into my office for a physical (his wife made him come). He was on no medications and warned me that he did not want any tests. I talked him into a prostate screening test, and a diabetes screening test. He has prostate cancer and severe uncontrolled diabetes. I almost feel like I gave it to him and in a sense, I did. He was living his life without any labels and now he has two he did not want in the first place.
I've said this before. Medicine is a funny thing. In a day's schedule filled with 15 patients with 20 minutes per patient sometimes, you have to be able to go from one room where you said "I have bad news: you have prostate cancer" to a 2-month old well child exam where you get to say "He's doing great!" For me, it's when the day is over and I am spent, that it hits me.
I joke with my patients a lot. We try to keep the encounter light. I can't forget though, that this is serious business and under the veneer of the routine physical exam, cancer and death may lurk.
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