Beware, Narcissus!

By now we have all seen the images. Carousers on beaches, partiers in bars, etc. The exuberance and perceived invincibility of youth which the government and media boosted with poor messaging. Modern incarnations of narcissus, so in love with their own beauty and youth they can see no other truths.

Sure, on a population scale, statistics are near destiny. However, on an individual scale, statistics are a poor substitute for adequate personal protective equipment.

Trust me, I know something about being the 1 in thousands. So does my wife and our first daughter. We were young, healthy, with access to good medical care. Statistically, we were destined for a healthy and uneventful pregnancy and healthy child.

Here is the thing about statistics, someone is that 1 in 100, 1 in 1,000, 1 in 10,000. And all the statistics in the world will not stop you from being that one.

At 3 weeks old we had to sit and hold our baby while she took her first and last breaths without a machine to breath for her. Statistics didn’t help me sleep. Statistics didn’t comfort my wife. Statistics didn’t soak up our tears in the middle of night.

Some of us young, otherwise healthy people will die from this. And the more people who get sick at once, the more of us and others will die.

The other side of those statistics is this: we all know 100 people, including people who are compromised or elderly. At the rate we are going, we will ALL know multiple people who will die from this virus. It will touch us all, one way or another.

As someone who knows about grief, do what you can to limit how many people you will have grieve over the next year. You may not be able to spend time with the people you love in their last hours because of restrictive hospital quarantines.

Someone you know, and in all likelihood, someone you love, will die alone in a hospital bed in the next year.

Why do anything which means this will happen more than has to?

Because it is inconvenient? Because it will cost money? Because it is boring? Because it isn’t necessary?

Because I don’t want to sacrifice for something which may not directly benefit me?

The Individual will No Longer Be King

We are at a deflection point in our nation’s soul. For the last 60 years, the role of the individual has increased in our nation’s psyche. Society and the good of all have occupied a smaller and smaller place in our national priorities.

This must change. This will change. The only way for as many people as possible to emerge from this alive is for all of humanity, but in our case, Americans, to remember we are part of something greater than ourselves.

Our petty desires and whims pale in contrast the great struggle humanity is embarking on. This is terrifying, but also an opportunity. Our dependence on one another, the bonds which keep families and communities functioning will grow clearer than they have been in a long time.

We are part of a whole. A mass of humanity, connected now more than ever. We must find where those connections can be nurtured, strengthened, and where each of our own gifts will contribute most.

Specifically, this is a calling to my generation, often known as Millennials to stand up and make our contribution. We must show up, we must act. This is the beginning of a great test as a nation and a generation. It has been decades since humanity has been called to such an epic task.

For some of us, it will be 3D printing of needed parts, sewing of masks, running to the front lines in hospitals, caring for elderly or high risk neighbors, getting groceries.

For others, this will simply be staying home. We will contribute to breaking the chain of infection.

We must not underestimate the courage of staying of home.

The act of staying home is no simple feat. Staying home makes real the fear of the threat we face. It would be much easier to pretend no threat exists, because no fear could torture us.

By staying home we sacrifice the sweet delusion of the absence of fear. It is worthy sacrifice, as we cannot be courageous until we have first felt fear.

Courage is resistance of fear, mastery of fear – not absence of fear.

-Mark Twain

So, I call on all of us to act courageously, to allow ourselves to feel afraid. We can only begin to know the depths of our collective courage once we have touched that fear collectively.

We cannot continue to hide our fear behind paper tiger statistics. We will not have truly entered the fray until we have allowed ourselves to feel at risk. We must show up and give of ourselves.

This means giving not what one wishes to give, but what others need. We must give what is so desperately needed, not something easily dispensed.

History has given us a moment to rise to the occasion. It is terrifying. Yet, it is an opportunity for us all to be our best.

Beware Narcissus, my fellow Millennials, live your best life, feel afraid, act courageously, stay home.

Image: Narcissus, by Michaelangelo Da Caravaggio, circa 1597 – 1599. Galleria Nazionale d’Arte Antica.

The Tide Went Way Out

When a disaster comes to the High Plains, the sky holds the warning. It has always been this way. The sky dominates the land on the plains. Of course it where the warning first appears.

When wildfire rushes across the plains smoke clouding the sky announces its imminent arrival. When the “black blizzards” rolled across the plains in the Dust Bowl their towering clouds of dust blocked out the sun on the horizon. The sky lets you know ahead of time.

Except this time it doesn’t. The sky is serene and blue as far as the eye can see.

The pace in clinic and the Emergency Department is slow. I have only been on staff here for about a month, but I know this is slow even for here. Physicals have been cancelled, colonoscopies postponed, the usual minor urgent care visit in the ED have effectively ceased.

I think of stories from the islands of the Pacific during Tsunamis. First, the tide goes way out suddenly, then the wave builds in the distance and it just keeps coming. As I stand on the edge of town, looking West at the setting sun, I feel like I am watching the tide rapidly recede.

I have spent the last 48 hours running around the hospital checking for what supplies we have, asking pharmacy techs to order more vecuronium (on backorder), steroids, duo-nebs, and morphine, oh God, please make sure we have enough morphine. I verbally underline the need to stay stocked with morphine to the pharmacy tech.

I repeat Dr. Edward Trudeau’s mantra in my mind, “To cure sometimes, to relieve often, to comfort always.” In a preparation meeting, I remind my colleagues Rural America looks demographically a lot like Italy. Mostly older, and in our case, very chronically ill.

We unfortunately have even fewer doctors and hospital beds per capita than Italy. This will swamp us, I emphasize to my colleagues. And our typically release valve, “transfer to higher level of care,” is going to stop working pretty soon, because it will hit transfer centers before it hits us.

I am preparing to practice mass casualty, battlefield medicine. I fully anticipate we will run out of IV fluid, IV tubing, etc at some point. I insisted we order 3% saline so we can mix it with D5 or Sterile water to make more normal saline than we otherwise would be able to order.

I made our pharmacy tech other oral rehydration solutions, feeding bags, and NG tubes. Once we realize we are getting low on IV supplies, hydration will have to be done orally, with NG tubes if necessary for the weakest.

Just like everyone else, we have started rationing PPE. Hopefully the supply lines catch up by the time it really reaches us. We will probably have a 1-2 week lag compared to urban centers.

When I get home, I completely strip, all my clothes go into the wash – on sanitize. I shower more thoroughly than I ever have. Only then do I get to kiss and hold my wife and daughter.

Like everyone else is saying, please stay home for us and our families.

20% percent of Italian healthcare workers have contracted the virus, when one out of every five healthcare workers is out and cannot work, more people than need to will die.

This is what I dread is coming….I hope I am wrong….but I don’t think so.

The Wave is Building

We all take comfort in our founding myths and narratives. The physical and social isolation of the High Plains from the coasts and cities allows people to act as though the problems of those places exist in another world. This time has been no different. People have reacted slowly and still aren’t sure whether or not to take it seriously.

I have been trying to create a sense of urgency without panic. A narrow balance beam to walk. I don’t know if I am succeeding.

I can feel the shocks of the formative earthquake rippling through my body, even if the wave is still not visible. It is corporeal. The wave is building, rising. I survey the horizon, there is no high ground. No where to run to. We are it out here.

The state has already told us not to expect extra equipment any time soon. The strategic stockpile is already spoken for.

Already, we are accepting low acuity patient’s from the nearest large urban hospitals in an attempt to free up bed space for them. Our normal Critical Access bed cap of 25 has been lifted to 35 beds.

The wave is building.

We really normally only function with 5 acute inpatient beds which normally hold the lowest acuity patients who would ever be in the hospital. We have one ventilator, and it is transfer vent. No bipaps, our nursing home is physically attached to our hospital – a disaster in the waiting.

We won’t be keeping anyone alive on ventilators out here. To try and do so would utilize valuable resources in the hands of physicians and staff who are not well suited to maximize that person’s survival.

The role I anticipate we will play is three-fold. Surge capacity for low acuity cases who simply need oxygen, hydration, and nursing care. We will likely provide convalescent care for people who are weakened after serious illness and sent out here to take the load off of urban referral centers. And, finally, hospice and palliative care.

We will comfort the dying. Comfort always. At some point this will be the greatest gift we can offer.

Death will Walk with Us

In a moment between meetings, I sit dumbfounded in my chair in front my computer. The photo is an Italian military convoy hauling trucks full of bodies out of Bergamo. This is different.

The wave is building.

As a physician, we have all interacted with death before. This will be different. Italy is showing us this now. I learn the next day, we don’t even have a funeral home in town. Our options are 20 miles in either directions.

I ask our emergency preparedness director what the plan for moving bodies out of the hospital is. She tells me the mass casualty plan includes a plan for bodies to stored in the community center until refrigerated trucks or another location can be identified.

Well, that’s at least something, I think and take walk to the edge of town to watch the sun go down.

It seems fitting that the edge of town is also the edge of the cemetery. I estimate the space left in the cemetery, probably insufficient. I guess it doesn’t matter much anyway. People’s bodies who die in a pandemic are supposed to be cremated anyway.

This is rural medicine in the age of the pandemic. A family medicine doctor is running around helping to creatively order supplies for the entire hospital. I am urging administration to build a list of somewhat medically trained people in the community to use as an auxiliary nursing force.

Trying to think of anything and everything we can do to keep people out of the hospital – I plead with our leadership to start building a framework of phone trees and community health volunteers to check on the vulnerable and elderly.

We need to compile and update a list of recovered people in the community, because in 1 month, they will be like gold.

I worry about where the dead will go.

This is our life now and for the foreseeable future. Acceptance will be key to maximizing survival, not only of individuals, but of communities and our way of life. We must not stick our heads in the sand.

Comfort always.

Photo: The Great Wave Off Kanagawa, c. 1829-1833. in Metropolitan Museum of Art by Katsushika Hokusai.

Mental Healthcare, Still Excising the Stone of Madness?

My phone rings.  I stop walking.  The sudden change in velocity causes the gravel under my feet to let out a slow grinding noise.

I often walk the gravel roads on the edge of town when things are slow, even at night.  Maybe especially at night.  Getting away from the few lights allows the full grandeur of the night sky of envelop me.

It is an expanse I rarely get to appreciate in the city where the smog and light pollution only let a few key stars shine through.

Of course, I am always within 20 minutes of the ED, but at my walking speed, that could be over a mile away.  I answer the phone.

“Hello?”

“Hey Doc, the police are bringing in a guy who has been acting strange and his mother called a safety check on him. So, they are bringing him in for evaluation.”

“I’ll be there shortly.”  I turn and head back to the hospital at a slightly faster pace than before.

The Rural Mental Health Crisis Team

I walk through the doors into the ED.  The standard mental health crisis is now assembled: Two small town police officers, an ED nurse, and myself.  God help this poor soul, because we probably won’t.  At least, not in any way which changes the trajectory of his illness.

“Hi,” Char, my nurse cohort for tonight begins. “So, this is Tim, his mom called the cops because he has been acting strange the last few days.  He is talking all the time, wouldn’t let his mom into his room in the house.  He has had a lot of problems with meth, so, y’know…”

I acknowledge Char’s statement, but also mentally try to put it on a back shelf.

One of the double edged swords of small town doctoring is everyone knowing everyone.  On the one hand, it is quite a bit easier to get a detailed and relevant social history on people.  On the other, people often have their story made up in their mind about who a person is and what is going on.

Could Tim be on meth? Sure.  Does the fact that he’s done meth before mean he is one meth now?  Not necessarily.  I have developed a technique of trying to mentally disprove the suggested theory while also proceeding as if it an equally likely possibility.  It seems to help me find balance in diagnosis.

If You Get Hurt on this Rotation, You Fail.

We did our emergency psych rotation in medical school in the ED of the county hospital, a level 4 trauma center in the middle of downtown.  It was the quintessential urban ED.  On orientation day, safety was the first and last thing addressed.

The attending psychiatrist, a tall, thin man who projected both bookishness and a tempered, pulled bowstring kind of hardness, listed some maxims:

  1. Do your first cursory exam from the door
  2. Never let a patient get between you and the door
  3. Try to project calmness
  4. If you feel unsafe, leave

He finished his talk with this warning: “If you get injured on this rotation, you will fail this rotation.”

Honestly, this was the scariest threat he could have made to a room full of medical students.

Whenever I find myself back in this situation, I stop at the door and do my initial exam.  I look Tim over.  He sitting in the bed, his hands flailing over his head in somewhat rhythmic circles.  If he’d had glow sticks, he would have fit right in at a rave.

“Tim, what’s going on?”

“Just keeping everything together.” He spat out in between his rave routine.

“Are you feeling okay?”

“Oh yeah, I feel great. I just got to keep everything moving.”

“Have you been doing any drugs?”

“Nope.”

“Do you know where you are?”

“Yes, the hospital.”

“Do you think anyone is out to get you?  Do feel in danger?”

“No, but people have been watching me, talking about me.”

“Who?”

“Everyone”

I review the chart.  His heart rate is quite elevated and his blood pressure his very high.  It could be meth, but he also seems to have some paranoia and something else going on.

Of course, true psychosis and meth intoxication are not mutually exclusive diagnoses.

“Give him 4mg of lorazepam IM, if he calms down, start an IV and give him and a liter of normal saline, he’s probably dehydrated and we’ll need some urine.”

Collateral History

I leave and call his mother.  She tells me he smokes marijuana still (of course, I think to myself, marijuana is just a vitamin these days). But, she continues, he hasn’t been acting like he used to when he was on meth.  He has been saying that he has been talking to his deceased father and repeatedly saying everything would be okay because they would be seeing him soon.  He has not been sleeping, eating, or drinking she goes on.

She runs through a disconnected description of the past few days.  She is clearly very shaken.

I return to the ED about a half hour after Char gave Tim his sedative.  He is out cold.  Rousable enough to avoid intubation, but way more sedate than someone psychotic on methamphetamine would be after that much lorazepam.  His vital signs have normalized.

His story is starting to sound more and more like true psychosis, possibly a manic episode.

“Okay, Char, I don’t think this is meth, we should get mental health here.”

“They won’t come til we have a U Tox which shows no meth.”

“Of course, well let’s get that urine then.”

We Count the Hours…..

What is understood between us is how long this is going to take.  The closest emergent mental health evaluator is 90 minutes away.  So, even if we immediately had a magical urine sample at that very moment, we would be 2 hours from someone actually evaluating him (which has to happen before we even discuss placement).

2 hours later, we finally have a urine sample.  We call the mental health evaluator.  She agrees to come.  I go out for another walk.

After Julie, the mental health person has evaluated him, we talk.

“He is psychotic and needs placement?  Right?”  I prod her.

“Oh yeah.  He definitely needs placement.  I have already placed him on a mental health hold. I am going to go start making calls looking for placement.”

“I love you already, Julie.”  She smiles back.

This is music to my ears.  I hate placing people on holds.  It is a huge legal move to restrict their rights and comes with a lot of paperwork.  I love it when someone else does it.  And placing them on a hold pales in comparison to the work of finding a mental health facility to take him, which she is already starting.

Seriously, I love Julie right now.

I stand up and turn to Katie, the nurse who has replaced Char.  This has already gone on so long shift change has already come and went for the nurses.  I am here for 48 hours, so no such luck for me.

“Call me when you have paperwork for me to sign, I am going to go to sleep.  He can have more ativan if he gets agitated again, I wrote for it already.”  I think about ordering him an antipsychotic, but since he is compliant enough on the ativan, I would rather the psychiatrist get to see him in his full psychotic glory rather than already partially treated.

I trudge off to the sleep room.

A New Day Dawns

I wake up to the phone ringing again.

“Hello,” my voice comes out a froggy moan.

“Hey Doc.”  It is Char again, shift change has already happened again.  He has now been here for 18 hours. “Need you to come out and sign Tim’s transfer paperwork, we have placement and transport is on their way.”

“Okay, I’ll be right there.”

I scribble the legal necessities on the paper work and finish my half typed note from the night before.  Honestly, I am pretty pleased at how relatively seamless this was.  It took a long time.  I feel like it went well.

Cynicism Creeps Back In

However, my cheerfulness quickly fades as I am honest with myself about the situation.  Sure, we did what we were “supposed” to do.  Theoretically, the ramshackle network of mental health on the High Plains worked.

If I am honest with myself, all it succeeded at was passing the buck.

I know from experience how this will play out in the end.  He’ll get stabilized on medications in an inpatient setting, then he will be sent back to the High Plains to the care of his elderly mother, where the closest psychiatrist is 2 hours away.  Even then, the psychiatrist is only available 2 days a week.

No one will have the power or will to make sure he stays on his medications.  One day, he’ll stop them, because self-medicating with marijuana feels better than antipsychotics, and eventually the cycle will repeat.

Who knows if he or anyone else will get hurt next time.

Dividing the Care of the Person

This is how we make ourselves feel better so our souls don’t rip in half.  We break down the tasks involved in caring for human beings into such small parts so we can all feel like we’ve “done a good job,”  All the while, for the person, nothing really changes.

This is our “system” of mental health in this country.  A revolving door of failure.

Sadly, I shouldn’t even complain.  I was thrilled to find out such services even existed. In large parts of rural America, the same patient would have been placed in the local jail.  In many towns, the jail is the only secure location in town for these people until placement can be found.  At least Tim avoided that fate.

I played my part in this farce brilliantly.  We efficiently and effectively “placed” Tim.  Who could find fault with my actions?

Of course, it is not my fault we have such a failure of a mental health system and my participation does not mean I own all of its sins.   Nonetheless, it is just one more of the millions of tiny cuts physicians endure to our souls while working in our healthcare system.

The history of mental healthcare is filled with terrible and inhumane practices. Will we look back on today the same way?  We might not be lobotomizing people anymore or cutting into their heads looking for the “stone of madness,”  but we should not delude ourselves.

Repeatedly sending ill people into a world their brains cannot process to self-medicate with drugs and endure repetitive trauma through physical and sexual abuse at the hands of each other is not a more humane choice.

At least the old quacks cutting the stone were actually trying to cure something.

Featured Image: Cutting the Stone, Hieronymus Bosch, 1494 or later.

What is Adulthood?

The tumultuous diversity of America is great gift.  Our dynamism as a country surely depends on the constant exposure to new ideas and ways of thinking.  On the other hand, it comes at a cost, too.  Community cohesion seems to be the cost we are paying for this wonderful engine of our country.

One of the binding forces of community is ritual.  Traditional cultures have rituals for all major life events.  These rituals bind us to one another and help us feel rooted in our people and place in the world.  One such ritual I often feel is missing in our culture is that of passage of into adulthood.

I think many of us reach adulthood at different times in our lives.  Clearly 12 years old is no longer the time for recognizing our transition into adulthood.  Yet, I think clarity would be helpful.  Those of us in Medicine often seem to have a prolonged entrance into adulthood due to the many years of schooling and training.

When did I become an adult?  At 18?  When I graduated college, or medical school, or residency?  Maybe, for us Millennials, the transition to adulthood happens when you have to start paying off your student loans?  I had a long slide into adulthood, slowly gaining more and more responsibility.

A little ritual to mark a moment might have provided some clarity.

Is responsibility what marks our transition to adulthood?  I am not so sure.  I always had a fairly large amount of responsibility, often more than my peers.  Yet, it did not make me feel more “adult.”

Growing up, adults are the ones who have the answers.  They teach us the rules of life.  They provide structure and certainty to young, expanding minds.  I know more thing than I ever have, but often feel like I have fewer and fewer answers to the questions which matter.

I still don’t really feel like an “adult.” I certainly don’t feel like I can offer anyone else any certainty.

Feeling Old

Yet, I do know what it means to feel old now.  Unlike adulthood, I learned what feeling old feels like within a matter of 2 months.  After the first, burning, searing weeks of grief gave way to a smoldering, tired blanket of grief.  Our first daughter dying made me feel old.  All of the sudden, I was world-weary and inexplicably brain-and-soul-tired.

It seemed as though the world had gone gray, and taken me with it.  Everything took more energy than it had before.  Then, the hospital-pharmaceutical complex came and demanded I keep performing my RVU tricks.  Any hope I had had of finding some comfort and solace in work and my supposedly noble profession was dashed.

I have hurt more deeply than I knew possible.  Yet, life keeps going.  Now, I visit my grief at times.  Sure, sometimes I feel guilty I can not feel it for a few days to even a week at a time.  Sometimes, when I feel guilty about having joy and pleasure in life again, I got back to the day we had to say good bye.  I remember holding her as she stopped breathing.  Soon, I am softly crying, and I know I haven’t stopped feeling her loss.

The grief of losing my daughter was by far more painful of the two wounds I sustained at that time.   No one should have to lose a child, but people do.  Sadly, it is more common than many realize.  A path exists, there are books, and people want to be supportive (even if they are often bad at it).   Maybe because of this, I have found the process of coping with her loss and healing from it to be simpler, if not easier, than coping with my disillusionment with Medicine.

You Can’t Turn Back The Clock

The repeated grief of coming face to face with my disillusionment with a calling I had had actually grown to believe in seems to be never ending.   The Hospital-Pharmaceutical Complex seems to take joy in reminding me of its callousness and love of profiteering.  It never fails to slip comfortably under the already low bar where my expectations are.

While I have come more to terms with the reality of modern doctoring, it still makes me sad.  Sure, sometimes I am angry, too.  But really, it is mostly sadness.  I don’t have the energy to be angry at a giant faceless industry.  That sadness seem to be the well which feeds my feeling of elderliness.

Before, I felt like I was participating the arena of Medicine.  I was an eager young pupil, ready for action. Now, I view the going-ons of all the little hospitals as an old man on a bench dispassionately watches a cat stalk a squirrel in a park.  It is a drama, but a small and distant one, separate from the man’s life.

Sure, it will be sad for the squirrel, but the world is simply this way.

Welcome to Adulthood

Maybe, I wonder, this is what adulthood is.  It is not rituals, nor accomplishments, nor financial responsibilities.  It is the world teaching you it is not a place of endless possibilities, at least no longer for you.  Is adulthood the place and time where we realize life can be just as cruel as it is wonderful?

Do we become adults when we transition from an excitement about how the world could be to a acceptance of how it is?  No longer the young revolutionaries, we become harnessed bureaucrats and accept our fate?

Maybe then, I was lucky to make it to 32 before I became an adult.  I had a long and wonderful childhood, full of joy and discovery.

On my better days, I hope to return there.

Maybe that hope means my transition to adulthood isn’t so foregone, after all…

 

Is This Path Sustainable?

I suffer the curse of rumination.  I ruminate, overthink, and ruminate some more  Strangely, I don’t tend to worry all that much, but I think on things, repeatedly, and often.  My ruminations have a tendency to make the simple complex, the joyful a morass of conflicted emotions.

A recent drive home across the Big Empty was fertile grounds for such rumination.  I had completed a 78 hour shift on the High Plains.  It was an easy shift.  I saw 10 clinic patients, 5 ED patients, one of which I admitted to the hospital.  None of it was particularly complex nor emergent.

For that amount of work, I made roughly 1/2 the salary that most outpatient family docs make in a month.  That is right, for 15 patients, I made about over a 1/3 of my income for the month.  You would think I would have been driving back home thinking about how I lucky I am to have found such a gig in modern medicine.

Instead, I became what my wife terms “thinky.”  I couldn’t help but feel somewhat guilty.  Imposter syndrome quickly followed the guilt.  Is someone going to figure this out and get rid of this?  What will I do then?

This clearly is not sustainable for the country…Is it sustainable for me?

The Stories We Tell Ourselves

Obviously, from a financial standpoint, I did not generate enough income from my physician fees to justify what I was paid (not to mention what the company I contract with got paid). I generally justify what I get paid with this knowledge:

The hospital pays me to keep the ED open, not to generate revenue. 

It is true, of course.  And a true free marketeer would simply say, “If someone will pay you to do it, it is the market’s will.”   A lot of people don’t want to do what I do, so my willingness to do it is worth a high price.

It may just be that simple.

Nonetheless, I often still feel like a profiteer.  My services are expensive. I can’t help but wondering why someone hasn’t figured out how to avoid using me.

Of course, this is not my problem to solve.  Plenty of people are paid quite well to manage these little hospitals, and if they can’t figure out a better solution, why does it bother me?

I keep speeding along open highway…

I stare at the prickly poppies in the ditch as they race past fenceposts along the green and tawny plains.  I can feel my brain chewing its cud.  The anxiety behind the above question is, of course, what will I do if they do figure out something better?

It is a real, yet remote anxiety, I turn down work every month.  There is too much need on the High Plains to fill.

How is there still so much work available that I am constantly turning down shifts?

Of course, I know the answer.  The High Plains are not for everyone.  It is tough country.  There are no beaches nor ski resorts to attract and retain doctors like resort towns have.

Moreover, hospitals tend to ask more and more of their staff until they quit.  Succession planning is not in the vocabulary.  Rural hospitals live from crisis to crisis. Part of this is the natural result of having shallow benches.

If a town only has 3 docs, all it takes is for one one to get sick, retire, quit, get in trouble with the medical board and you are suddenly asking your docs to take every other day call.   The call schedule for the rural Emergency Departments is like Jonathon Edward’s God:

The God that holds you over the pit of hell, much as one holds a spider or some loathsome insect over the fire, abhors you, and is dreadfully provoked;

-Jonathon Edwards, Sinners in the Hand of an Angry God

The Rural ED Call Schedule takes but a faintest provocation to throw the lives of its participants into absolute chaos.  It only knows how to ask for more.  Living, day in, day out, under the guillotine a rural ED call schedule is knowing your kids’ games, family dinners, trips with friends all hang in a delicate balance.

They could all be lost at a moment’s notice.

It is not for the faint of heart.  It is also a stress which the non-clinician cannot know.  Managers of rural hospitals ignore the psychological effects of living under that cloud at their peril.  Unfortunately, most do and turnover is constant.

As long as a cost-based reimbursement continues to be a policy of Medicare, I will have more work than I know what to do with.

Cost-Based Reimbursement, the Lynchpin

I have mentioned cost-based reimbursement before.  It is absolutely the only reason Critical Access Hospitals are able to use me and not go broke.

The basic tenet of Cost-Based Reimbursement(CBR) is that for a given hospital stay in a Critical Access Hospital, Medicare will pay 101% of the “cost” of providing services to that patient.  Who gets to decide what is included in that cost?  The hospital.

So, because my fees can be included in the cost of providing an inpatient stay, they can be written into the CBR formula.  Of course, if I am in the ED seeing a bunch of patient’s, this cannot be included in an inpatient cost report.

So, hospitals have to report how much time a physician spent on an admission, rounding, other inpatient tasks.  Then, they can roll that percentage of my fee into their cost report and get reimbursed for it.

In short, without cost-based reimbursement, I would likely be out of a job.

Though I am technically a “business” as a 1099 sole proprietor, my entire income hangs on government spending at its root. This is the reality of most of healthcare in this country.  Sure, some people have private health insurance, but public healthcare spending is what keeps the lights on around this county’s hospitals.

We would do well not to forget that.

So, is it Sustainable?

I decided to write this post for one reason, to break my rumination cycle.  Sometimes, putting thoughts down on the blog helps release them.  The reason a cycle keeps going because I have no definitive answer.

Clearly our current healthcare system is unsustainable.  Cost-based reimbursement may be as well.  However, I am hardly alone in making a very good living off the healthcare system without necessarily adding that much value.

On the other hand, rural locums is common in plenty of other countries with systems less screwed up than ours (New Zealand, Australia, UK, and Canada).  So, this might be plenty sustainable.  Like every thing else in healthcare, we all know it can’t keep going like this forever, but it might go like this long enough for me to finish my medical career.

I guess this is gig will be sustainable until it isn’t.

Featured Image:  Path in the Forest.  Spruce Forest.  Ivan Shishkin, 1880.

Can Physicians Resist? Or Only Vote with Our Feet?

The Culture of Medicine values orthodoxy.  The requirements for getting into medical school are extremely rigid and in no way value aspects of an applicant not easily testable or quantifiable.

Indeed, the various hoops, tests, and checked boxes of getting into medical school seem more designed to weed out renegade, innovative, creative types than to assure a high caliber of applicant.

They select for the correct quality of applicants, not the high quality of applicants.

Medical school admission seems primarily designed to identify individuals who are adept at learning the rules of the game and then driven to win the game.  Anyone who questions the game is summarily excluded.

As a cadre, physicians are poorly equipped to resist the Hospital-Pharmaceutical Complex.

We are acculturated to shrink our purview to the smallest area possible. This makes it easier to control all of its aspects, which soothes our control-oriented personalities (also selected for in the admissions process).  However, it also dilutes our influence and robs us of seats at the decision-making tables.

Yet, many, if not the majority, of us are extremely dissatisfied at the state of American Medicine. I have written plenty about this.  If we are so dissatisfied, why aren’t physicians across the country rising up and demanding change?

We don’t know how to Resist

Physicians spent their high school and college years languishing in libraries and study halls.  We didn’t go to trainings in direct action.  In residency there are no rotations in “managing organizational change.”

We are so focused on getting the “right” answer, we have rarely had the opportunity to demand those asking the questions defend their choice of question.  Give physicians a set of rules to a game, and we fight tooth and nail to prove we can be best.

Ask a group of physicians whether or not the game is just, worth playing, or if the rules should be changed and we just stare blankly back at you. Those questions have no winners, it does not compute.

For sure, we are raising our voices at higher rates than we ever have in the past.  Yet, the machine keeps jugging along.

Debt, Competition, and Greed

Maybe it is as simple as too many of us are debt-indentured.  The vast majority of us start with $200k+ in debt in our early thirties and then add a mortgage and often some other consumer purchases as well.

Are so many of us permanently debt-indentured to the point where all we feel we can do is just keep our heads down, pay off our debt, and get out?

I slammed my head against the wall for 12 months in my first job. I tried incrementalism from the inside.  It was terrible, and when tragedy hit, I didn’t have the stomach for it anymore.

No one ever articulated what we were working towards. What change were we really trying to make?

Of course, I learned no one was trying to make change.  They were just trying to make as much money as possible, for the system, and then for themselves.

My partners just agitated for more money for less work with a better schedule without the EMR. Their passion had withered to greed and self-interest, cloaked in the name of patient care.

Effectively, they were still applying to medical school.  They were just just trying to win the game.

They didn’t care that the game was corrupt and the purpose of the game was completely divorced from its original purpose.

Or, has this always been medicine?  Has medicine always been a dichotomous beast of greed in the name of helping others?  Test, cut, prescribe until we are wealthy enough retire to a golf course community?

Have those who couldn’t hold their noses any longer always just left?

Is that our only option, to vote with our feet?

Is There Another Way?

At least in rural medicine, it seems as though all physicians can do is vote with their feet.  It seems so dissatisfying to have that left as our only option.  Also, as the problems of the healthcare industry are truly national in scope, there are few places left to run.

No real competition for physicians exists because the industry leaders have all embraced the same models which perpetuate burnout. As we are squeezed more and more to “produce,” our time and energy doesn’t allow for resistance and fighting for change.

Normally, it is the young and energetic who push for change.  The newest generation of doctors emerges into a field where all their excess energy must be tapped towards getting out from under a debt load. One reasonably measured in fractions of a million dollars.

We debt-laden young physicians have nothing left at the end of the day to offer the fight for change.  As such, our voices are largely silent in the national arenas, except of course on the impotent platforms of social media echochambers.

Instead, healthcare “industry groups” and our National Academies usurp the right to speak for us.

Our supposed representatives mostly seem hell bent on protecting or increasing reimbursements for their loudest members, not on making doctoring a fulfilling vocation again.

Surviving the healthcare industry has sadly become our goal.

I certainly hope something or someone comes along as a realistic option to fight for change, but my hope is mostly vestigial.  It is a mere remnant of an idealism and passion which seem a bygone memory.  Pretty soon, the only place left for our feet to go will be out of medicine entirely.

Honestly, I don’t think I am smart enough, connected enough, nor strong enough to find this other road.  I would love for someone to show it to me, though.  I would love to follow someone on that journey.

I do not believe I have the strength or skills to lead anyone in hacking a path out of the wilderness we are in.  Besides, I have proven myself to be more than content with wandering.

After all, the wilderness is a fine place, we could use more of it.

But the Restlessness was Handed Down…

But the restlessness was handed down,

and its getting very hard to stay.

-Billy Joel

I have not stumbled into this life of an itinerant doctor through some accident.

Ever since Cain and Abel, humans have been telling stories to try and understand why some sew and harvest while others roam with the seasons.

We all lie somewhere on this continuum.

On one end are the constant roamers, the nomads.  Those whose breath is the very wind over the plains, constant motion.  On the other end are the sewers, reapers, and builders.  Those settled ones who grow deep roots.

Most of us are in middle, but we all lean one way or the other.  I am center-nomad.  From the top of a far bluff, I look down at riverside settlements and envy the apparent stability and contentment.  Nonetheless, despite my longing, I am not of townsfolk blood.

I envy that life until I have it, then I quickly feel a deep need to move, to travel over the next hill, to see new country.  35% settled, 65% nomad.  These are impetuses difficult to resolve within one’s soul, let alone with the outside world.

Who Was I Kidding?

During medical school and residency I read a lot of the “happiness” literature.  A consistent theme in the happiness literature is community and connectedness.  As I started to make plans for a future practice, I folded in the importance of connectedness into my plans and landed on family medicine for a specialty.

I thought putting down roots and developing deep, long relationships with my patients would be satisfying and fulfilling.  In retrospect, this seems a little foolish – knowing who I am.  From graduating high school until residency, I never lived in one city longer than 9-10 months. Even in medical school, I figured out ways to spend months away from the city my medical school was in.

I spent 2-3 times longer in one place during residency than I had in the ten years prior.  What made me think I was going to suddenly want to settle down and become the “town doc” for 20 years?

I even thrived on the rotational nature of residency.  I loved having something new to learn and focus on every 2-8 weeks.  I probably would have gone crazy without it.

Indeed, family medicine is the nomad of medical specialties. The variation in family medicine was also a huge pull for me. We are not confined to an organ system, an age group, a location of practice, we can go where the wind of medicine takes us.

Pretty much immediately upon starting practice after residency, the sense of permanency began to suffocate me.  I couldn’t shake the idea of “this is it?”  Was this really the end point in the long journey towards becoming a doctor?

A nomad cannot be fenced.

I Know the Grass Isn’t Greener

Some may scoff at my acceptance of my rolling stone nature.   “Sure,” they say, “we all fall into the trap of thinking the grass is greener on the other side of the fence – but it isn’t.”

I agree.  I do not think the grass is greener on the other side of the fence. In fact, experiencing different places has helped me know this more definitely.  Rather, I seem to possess a deep desire to simply experience the grass on the other side of the fence.

I don’t feel the pull to roam because I am looking for something or somewhere better.  I simply have this greedy urge to experience everything I can.  Life is so short and there is so much out to feel, know, and experience in this world.

How can I say no?

There is so much to learn about the other side of the fence I could not have known until I was there.   Up on crossing a fence, I have realized the grass may be the same, but the fence is totally different from the other side.

I may not have crossed the fence to experience this, but it was a new experience all the same. An experience which I could not have anticipated.

Unknown Unknowns

To paraphrase Donald Rumsfeld, the world is full of unknown unknowns.  We can only experience them if we go new places, if we challenge ourselves, if we allow ourselves to be uncomfortable.  Discomfort is where growth happens.

This change in perspective, when repeated, is vivifying.  I am constantly learning to see the world through new eyes, which has added value to my life, if not wealth.

Some of us build monuments and harvest crops, others roam and explore.  We only thrive when we embrace who we are.

Featured Image: Der Wanderer uber dem nebelmeer (The Wanderer Over the Sea of Fog), Caspar David Friedrich.  1818

Rural Medicine: Reaching the Limits

The world of Critical Access Medicine is unknown to most physicians.  Lots of reasons exist to explain this.  Most physicians come from rather privileged backgrounds – read urban/suburban/well-educated.  Outside of vacation, their exposure to Rural America is very limited.  They simply do not know what is out here.

Medical training largely does nothing to address this lack of familiarity.  In general, medical training concentrates physicians in large cities right at the time time they are beginning to have families and start careers.  This makes moving somewhere else after training even less likely.

The culture of large teaching centers glorifies the specialist and high-tech, high intensity medicine. Physicians who teach in these centers often denigrate “community practice” as somehow behind or inferior.  Moreover, physicians who practice in urban areas often cite the lack of resources as an impediment to good care.

I have met physicians who have all or some of these biases against rural medicine.  The lack of resources, however, is absolutely a real issue.  I run into it on a regular basis.  I understand other physician’s frustration.

Multiple times on my last shift, I ran headlong into barriers to providing care.

Making Do

On a recent shift, a woman came in with the complaint of weakness and slurred speech.  Upon seeing her, I immediately called a stoke alert.  I do not work in any hospitals with a neurologist, let alone a “stroke team.”  Some have telemedicine robots so a stroke neurologist can evaluate a patient remotely.

This hospital does not even have the robot.

In most Critical Access Hospitals, lab and X-ray are not in house until you call them.  So, we worked on getting things started: drawing blood, placing IVs, etc.  I did an NIH stroke scale, 11.  The score met diagnostic criteria to consider tPA, if her other factors didn’t disqualify her.

Finally,  tech X-ray tech arrives.

“I need a stat CT of her head.” I initially received only a blank, sheepish stare in response.

She looked at me, at the patient, and back to me.  The X-ray tech leaned towards me and asked under her breath, “How how much does she weigh?”

The bed scale registered an astounding 472 lbs.

I turned to the X-ray tech, “That is above your scanner limit, isn’t it?”  She nodded up and down.  I knew the next closest CT scanner was 30 miles away, the hospital is slightly bigger (they have surgery capability and visiting specialists).

“Call Otherton and see what their CT scanner can hold.” The X-ray tech ran off to call and ask.  The one room ED was milling with people –  family, EMTs, nurses.  None of them doing much at that point, save for the lone nurse struggling to get an IV in the patient’s difficult habitus.  This was the most exciting thing to happen in this down for weeks.

After a few minutes, she returned.  “Their limit is lower than hours.”

“Of Course it is.” At this point, I had already accepted this is not going to go my, nor the patient’s.  I grabbed the phone to call the nearest stroke center, almost 3 hours away.

The long distance consult/transfer conversation follows a script.  Patient’s name, brief past medical history, brief story of what has happened.  In the case of a stroke, special attention to presenting physical findings and last known normal is the expected.  Then, I get to the meat of my call:

“So, the real struggle right now is she is well over the weight limit for our CT scanner and the next closest CT scanner is 30 minutes away and apparently has a lower weight limit than ours.”

Then, I heard something I have never heard from another physician on the consult line.  The stroke neurologist offered a simple line.

“I’m sorry.” This was quickly followed by, “Yeah, let’s just get here as fast as we can.  She is already out of the tPA window, we’ll finish her evaluation here.”

We sent her by ground ambulance as quickly as possible.

We Don’t Have That

The next day, an ambulance arrived with a 40s male, actively seizing for 20-30 minutes after the police arrested him.  No IV’s were placed in the field, he is completely unresponsive.  We quickly placed an IV and began the rounds of diazepam.  Finally, after three rounds, his seizure activity stopped.  He was still unresponsive.  GCS of 7, even after watching for any post-ictal improvement.

I have learned at this point it is more effective to ask for certain items rural EDs keep in bundles rather than what you would, ideally, prefer.  So, I didn’t as for my preferred induction agent, paralytic, etc.  I just asked them to bring their RSI kit, video laryngoscope (if they have one) and regular laryngscope.

“While we are getting ready to intubate, can someone get some IV keppra ready.”

“We don’t have that.” I am told.

“Fosphenytoin?”

“Umm, I don’t think so.”

“What other IV anti-epileptic medications do you have other than benzodiazepines?”

“I don’t know, maybe ketamine?”

Practicing medicine in a Critical Access setting is not a smorgasbord.  It is an 8th grade cafeteria line.

You can have whatever you want as long as it is Salisbury steak.

I proceed to intubate.  Afterwards, he was thankfully easy to bag and maintained end tidal CO2 and Oxygen levels in desirable ranges.  I asked if we have a ventilator.  An eager EMT piped up.

“Oh yeah, it is right over there.”  He pointed to a machine sitting on a crash cart with a big red sticker on it, “Out of Service.”

“Oh, I guess not.” He sheepishly admitted.

“Okay, bag him, make sure not to hyperventilate.”

Luckily, we have already called the local Medevac crew for critical care transport. They arrived and hooked patient onto their ventilator.  Carefully, they moved him with all his the sedation drips and IV fluids to their stretcher and flew him off to somewhere with an ICU.

Somewhere with a functioning ventilator and some damn Keppra.

I looked around that the remaining EMTs and nurses.

“Well, that could have gone worse.”

Why Do This Job?

I have talked to a fair number of EM residency trained ED docs and I often get the response of, “Oh, practicing out there would terrify me.”

I have no MD back up, no specialist support other than what can be obtained over the phone.  The EDs are often minimally staffed and under-provisioned.  On the other hand, my shifts are rarely so eventful as this.  Usually, it is Urgent Care level work ups. Often times it is downright boring – 24 hours without a patient sometimes.

But, that is the thing with an ED, anything can show up, even if it usually doesn’t.

I think a lot of quaternary care center trained physicians bristle at the resource limitation.  “I just wouldn’t feel like I am doing a good job.” is another statement I have heard.

I actually understand these concerns, no one likes to feel like they are providing less than the best care.  My response is simple.  The patients I see can’t call 911 and get dropped off at a Level 1 trauma center.  They are 2.5 hours from a level II, 30 minutes from a level III, minimum.

You can only take care of patients where they are.  Patients in Rural America need medical care just like patient in Urban America, but that isn’t where they are.  It’s called Critical Access for a reason.  Doing what is possible when you must is often more meaningful to the patient as doing everything because you can.

Time is of the essence in so much of what we do.  Waiting 20 minutes for a BLS ambulance to arrive and then driving another 30-45 minutes to the next closest Emergency Department could have meant serious brain damage for the man that man.

Could I offer him everything?  Of course not.  But I offered him a hell of lot better than 30 minutes of seizing in ambulance.

The famed bank robber Willy Sutton once answered the question, “Why do you rob banks?” with a simple, “Because that’s where the money is.”

I suppose, in the end, my answer is just as simple.

Why do I do this job?  Because it’s where the patients are.

Featured Image: The British Army in the United Kingdom 1939-45 Soldiers from 24th Battalion, Hampshire Regiment scale an obstacle during ‘toughening up’ training in wintry conditions at Wateringbury in Kent, 20 January 1942.

 

 

What is Being Present Worth to You?

…Memories of presence…the intensity of interacting with another human being that animates being there for, and with, that person.

Arthur Kleinman, The Lancet, Vol 389 June 24, 2017 Pg 2466.

“Doc”

“What do you have?” I ask the paramedic with the clipboard standing in front of me. The ED is rather busy. I am trying to arrange transfer of a man with an intra-abdominal abscess and one with neutropenic fevers. The prospect of more work does not excite.

Hank, an older paramedic who really enjoys the “medicine” part of his job, launches into his presentation.

“Rex Mayfair is a mid-forties man with a history of metastatic prostate cancer, Stage IV presents with urinary retention since this morning. This happens occasional for him and he comes in and we place a foley and have him follow up later. I already bladder scanned him, 570ml, and our scanner has been underestimating lately. Can I place the foley? He’s hurting.”

“Any fevers, weakness, blood in his urine?”

“A little bit of blood earlier, none now. Otherwise no changes from his baseline. He is not currently undergoing treatment for cancer, but is not on hospice. Can I place the foley?”

“Sure, go ahead. I’ll be in a bit.” I am relieved he has such a simple complaint. Something straightforward. Shouldn’t slow us down too much.

I return to organizing antibiotics and transfers for my other two patients.

Cancer Just Sucks

Eventually, after I tie up some loose strings, I make my way to Rex’s room. By the time I get into his room, Hank has already placed the foley, 1000ml out, and Rex is feeling better. My participation is really only procedural – a physician needs to physically see every ED patient.

I have a confession to make, I hate cancer. I hate how all consuming it is. As someone who initially trained in family medicine, cancer makes me feel as though I have already failed. The time for prevention was long ago. Now we sit at the mercy of the tumors.

Bad cancer makes me feel helpless. Doctor’s hate feeling helpless. Rex had bad cancer, and he was young.

Walking into the room, seeing Rex’s young, gaunt face makes me want wrap this up as quickly as possible. I only need to make sure there is no reason to suspect this is something other than swelling related to the cancer and I can rush him on his way. This should be quick…

To be Present or…not

“Hi, Rex, I am Dr. HighPlains, are you feeling any better after the foley?”

“Oh yeah,” Rex says in a defeated sigh. “It is better now.”

He just looks so damn tired and weak. I inhale deeply, but shallow enough so Rex didn’t notice. I sit down in a chair, recline slightly, and prepare to be here for a while.

After a few perfunctory ED questions, I asked Rex how things were going otherwise.

“It sucks, y’know, it just sucks.” He admitted.

“I can only imaging how much it sucks.” My patterned doctor-speech.

“I hurt all the time, cancer is in my bones. My hips and back, they ache all the time and then trigger muscle spasms.”

Without probing, he tells me how his urologist diagnosed him after 8 months of treatment for prostatitis. He describes how he was on hospice for a bit, but didn’t want to have a catheter permanently yet, so now he is not on hospice, but not pursuing curative treatment.

I simply nod in silence. His eyes are sunken and tired, but whenever he looks up, mine are there to greet his and hold his gaze as long as he desires it. He pauses frequently, but never seems done.

He continues, again without probing. He decided not have chemo because he has a form of muscular dystrophy. His oncologists told him the chemo would render him bed-bound from weakness.

“I would’ve had no quality of life…it just sucks, y’know.” He trails off into silence.

“Yes, it does.”

You Don’t Have to Ask a Dying Man

What do you say to make someone who is dying feel better?

It is a trick question, of course. Not because there is nothing to make them feel better, rather the thing involves no speaking. The answer, it turns out, is simple: you listen.

You listen. Even when it makes your own heart break, you listen. You listen through the descriptions of pain which makes you wilt. You don’t have to ask a dying man anything.

If you listen, he will tell you everything he wants you to know.

Rex isn’t done. He tells me about the facebook groups he’s found, which have been helpful to fight the isolation of living in the middle of nowhere with end-stage cancer.

He describes how much he used to enjoy driving the bus which took local elderly to events in the city and hearing their stories.

He misses that.

He tells me again about the pain. He tells me how his doctor prescribed him oxycodone for the pain, but he doesn’t like taking it. It makes his sleepy.

He has two little girls. When he took the oxycodone he just slept all day. His voice trails off, but I hear the implication.

He would rather be awake in pain with his daughters than sleep away whatever time he had left with them.

“It just sucks y’know, I’m only my forties, not an old man. Shouldn’t have to have a tube up there….it just sucks….” He bows his head, the brim of his baseball cap hiding those eyes, deep-set in his sallow, bony cheeks.

At that moment, it was a good thing I was listening, I couldn’t have said anything if I’d tried. I was speechless. My mind whorled in appreciation for the beauty of his simple statement.

“I have two little girls, I just slept all the time.”

This man, who has all the right in the world to numb himself from the pain of his situation had decided being present with his family was worth the pain.

Maybe when someone tells you the name of the thing which will probably kill you, time becomes palpably more dear. I don’t know.

What would I suffer through to give my daughter better memories of her father? What would I suffer through to have those memories and make more for as long as I could?

Few of us face a choice so stark, but in some way or another, we all face Rex’s choice. We can choose to be present in our lives and in pain, or choose to chase numbness.

I sat in a room with courage that day. I sat in a room with a man who chose to live his life rather than run from death.

Occasionally, if we let ourselves, we can awed by those we see through our practices But, we have to let ourselves sit in acceptance and receive the gift. I could have easily kept moving and had Rex on his way.

Instead, I sat down, and I am richer for it.

Featured Image: The Artist’s Father in His Sick Bed, Lovis Corinth, 1888.

Lockjaw Still Lives Underground

“Alright doc, I have a 6 year old who fell in her back yard in the dirt and cut her right palm.” Bill, the ED paramedic gave me his report.

“Do you think it’ll need stitches?”

“Probably”

“Grab a suture tray, 1% lidocaine with epi, and 5-0 prolene. I’ll numb it up, wash it out, and we’ll get her home.”

I walked into the room, introduced myself and took a look at the wound. 4-5 stitches would likely do the job. It was a clean, straight cut – the easy kind to close.

“This should be quick'” I think to myself.

I love lacerations, they are the closest thing to actually fixing something I get to do in my practice. Someone comes in with an injury, they leave put back together. It usually isn’t terribly hard, but it is a discrete problem with a discrete solution.

It is a nice break from the parade of our health system’s failures I usually see.

Isn’t there always a catch?

I numbed the wound and irrigated it. It was straight, clean, and pink in her hand. About 2 inches long. I quickly placed 5 simple, interrupted sutures and it came back together nicely.

I told Bill the kind of dressing to place on it, inverted my gloves, and threw them in the trash.

Offhandedly, I asked her mother, “And she’s had all her vaccinations?”

“No, we don’t vaccinate.” Her mother responded, as if it were an integral part of her moral compass.

“Goddamnit.” I think to myself. “This was supposed to be a simple lac.”

I turn around, sit down on the stool and look seriously at the mother.

I start in calmly but firmly, “Tetanus is a soil microbe. It is everywhere. There is real risk she has been exposed because of where she cut her hand open in the dirt. Now we cleaned it out as best we could, it is very unlikely she would contract tetanus, but if she did it would be a life threatening illness. What would you like to do?”

I had to breath slowly and calmly through the silence until she answered. “We didn’t have to be here having this conversation,” I think to myself. “She chose this.” I fumed internally.

Love, Fear, and Distant Demons

I saw her expression change from defiance to honest concern. I had seen that face before. My annoyance softened, I know most parents who don’t vaccinate honestly think they are doing what is safest for their children. They love their children like I love mine, they want to keep them safe.

The world is a big, scary place, full of things capable bringing harm to our children and our families. We assess these emotionally. The more fear they generate in us, the more threatening they appear. In the end, as human beings, we worry most about the dangers we feel to be closest to our families.

The face she made was the face I have seen other parents make when a danger once felt to be theoretical becomes real. I saw that face when I had told an expectant mother she was not Rubella immune (because her mother had decided she didn’t need any vaccinations).

I explained if she were to get rubella it could cause damage to her unborn child.

The knowledge that she could not undue her mother’s decision until after the pregnancy only made the fear more real. I looked into the mother’s face of the child with the laceration now and saw that same look.

It is the look of previously dismissed dangers made manifest. Of looking at a real and present threat, not weighing theoreticals and philosophical “freedoms.” It is the look of talking about the possible illness and death of your child.

It is a look I didn’t have to see that day.

Cursing Our Impotence in the Face of Death

Soldier Dying from Tetanus – Charles Bell (1808)

When I think about vaccine preventable illness, it is hard to communicate the despair and sadness doctors and nurses feel about them.

I think of a 5 month old baby I once cared for as a resident in the PICU. I think of watching his tiny body convulse in status epilepticus. He was unvaccinated and had streptococcus pneumoniae meningitis.

His mother just hadn’t gotten around to vaccinating him, she had no moral objections. Things just got in the way. To this day, I am not sure which is worse, but the “why” didn’t matter to him.

As we loaded him with ativan, then keppra, then phenobarbitol his seizures eventually abated. I remember the PICU attending looking at us during rounds and saying softly under his breath, “This will not be a good outcome, he will not have a good outcome.”

He, like all of us, were looking for ways to distance ourselves from tragedy. Using the language of peer-review and metrics he isolated himself from the picture he saw in his head of this child’s future.

He had been previously healthy, on a path to a normal life. That future was now gone. He would have permanent brain damage – probably a crippling seizure disorder for the rest of his life. He would become one of the “chronic kids.” Who are in and out of PICUs their entire lives.

He survived that hospital stay, but his life was forever altered. It is so painful to watch these things because society places its hopes and dreams in children. As adults we glory in their blanks slates, their possibilities.

We put on them the hope of correcting the failures of current generations. It is a lot to bear, being a child, being the symbol of hope and the future for a whole society.

As physicians and nurses, we watch this suffering and know it was not random chance, something simple could have prevented it. We seethe with rage, because accepting and living through the sadness would be too much to bear. It is easier to be angry, to blame.

We are furious someone has taken that future, has destroyed a receptacle for our dreams. Yet, anger gets us nowhere. Sure, we feel righteous, but it changes nothing. Its only real purpose is to insulate us from feeling the true depth of tragedy.

Our rage is for us, not for the child who lies attached to a ventilator. My anger certainly did that boy no good.

A Pound of Cure

Back in the ED, the mother and I discuss options. Being a struggling, rural hospital, we don’t have tetanus toxoid on hand. The nurse manager tells me they can have it by tomorrow, otherwise they will have to go to the City to a facility that can administer it. Either today or tomorrow.

We do have vaccinations. Hesitantly, the child’s mother agrees to a vaccination. She balks at the compound vaccine that also protects against pertussis.

“Do you have just the Td? Without the pertussis part?” She asks.

I mentally roll my eyes. Apparently, only tetanus now seems real. She is willing to have her child inoculated with the human blood product of the toxoid, but is only willing to have the minimum amount of “vaccine.”

I don’t go into long explanations about deaths from whooping cough, how it is not eradicated, how it is a real disease. I have already had too much magical thinking for one day.

We give her daughter the Td, and make arrangements for her to go to the City to get the tetanus toxoid. It seems like such a farce. So, much unnecessary effort and risk for something that could be so simply prevented.

I watch them walk out of the ED, it is hard to let the anger go with them.

It Feels Personal

As people who regularly battle death and provide comfort and care for the suffering, the rejection of vaccines feels like a personal affront. So much suffering and premature death occur in this world over which we have no power.

The idea of choosing to increase the risk, of adding more suffering unnecessarily, cuts us to the quick. We know these old disease, the previously forgotten harbingers of death. As physicians and nurses, we see the rare case that sneaks through modern defenses. They are still real to us.

We keep their secrets, we still study the demons who live underground. We know in other countries they still kill people by the thousands. Those monsters are still real to us, they keep us up at night.

We go home and kiss our children and thank God there is at least one threat in this big, dangerous world from which we can easily protect them.

This is why we respond with so much anger and vitriol sometimes. It is because vaccine preventable disease hurts us so deeply. We bear witness to so much suffering, because this is out job.

But to have suffering added to our plate, to have it piled on unnecessarily – this can be too much to bear.

Deep down, I know people love their children and are trying to protect them as best they know how. I only wish I knew how to make them feel the fear of those long-forgotten demons who still live underground.

If they were to live with the fear we know, I don’t think we would even be having these conversations.