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.

Walking the Ghost Road

Working as a doctor in small towns on the High Plains, I have learned to do without a lot of luxuries. Those practicing in larger centers would consider many of these things necessities, such as being able to consult someone to the bedside, ever.

I do, however, have one luxury that is exceedingly rare in world of Modern Medicine, time to reflect. As I often only see 5-10 patients in a 24 hour period, I sometimes have a good deal of this.

Moreover, now that I have an infant at home, the time I have to reflect while at work is even more precious. I have yet to find a way to sell my 2 month old daughter on the value of quiet contemplation.

Since high school, I have tended to reflect while walking. When I screwed up a test, or embarrassed myself at school, that evening I would go on a long walk, sometimes for hours. I would meditate to the slow movement of my small town past me.

I still do this. Today, I took a walk on the slight hill above the hospital. A “wellness path” winds its way through the buffalo grass, prickly pear, and yucca. I walked the path in laps, waiting to be called in.

Those Who Came Before

Halfway through a lap, I came to the single grave that marks the halfway point. It is a modest affair. A small white headstone with only three letters marks the spot.

The earth over the grave is covered in the same high plains vegetation as the nearby pastures. Prickly pear and rabbit brush grow up around the headstone. Eventually, someone erected a very sturdy pipe fencing around the grave, likely to keep cattle from rubbing on the grave marker.

Perhaps most interesting, this lonely, solitary grave belongs a fellow physician. In the late 19th century, a wayward doctor had settled in this water stop town on the railroad. The townsfolk laid him to rest on a slight hill that overlooks the shallow, cottonwood-dotted valley of a seasonal stream.

I lean against the iron fence and stare up at the night sky. It is a wonderfully clear and dark night. I savor the lack of light pollution and the horizon to horizon views. Scanning the southern sky I see the milky way.

The Ghost Road

In Lakota cosmology, the milky way is known as the Ghost Road. It is the path all spirits must walk on their way from this world to the next. I let myself get lost in the imagery of walking through the galaxy as a spirit.

As I imagine my spirit side-stepping stars, I remember my fellow physician next to me. He walked that road over 100 years ago as a young man. Less than forty, it looks like. It is near impossible to imagine the life and profession of a true frontier doctor.

Nonetheless, profession and location bind us together. We have both doctored and cared for people in this little town. Even if the march of time makes it impossible for us to know each other as people, we are related.

This is also a Lakota idea – Mitakuye Oyasin – We Are All Related.

I reread the plaque explaining this grave.

A Life in a Paragraph

The good doctor had arrived in 1880. Two years later smallpox erupted in town (could he have imagined an era when doctors would have never seen a case of smallpox?). An old cow puncher came down with disease, and the good doctor cared for him.

The old cow puncher recovered, but the good doctor contracted smallpox. He eventually succumbed to the disease and was laid to rest on the same lonely windswept piece of prairie where I talk my contemplative walks.

“A good doctor…and a good man.” The plaque states.

Does the brief story on the plaque have meaning for me as a physician?

This physician died in the service of others, and I complain about not feeling fulfilled by modern medicine. In his calling, he sacrificed everything. Noble? Maybe, but also a complicated legacy.

From the plaque I also learn that he left behind a wife, who had accompanied him from the East. It does not say what happened to her out on the alien High Plains, alone, in grief. He also left behind an isolated, frontier town without a doctor.

How many went undoctored in his absence? I will never know.

Doctors Get Sick, Too

The irony of his death from the disease he was treating is not lost on me. Physicians are part of the societies they inhabit. Inextricably linked. In medical school, I often heard vague citations that physicians have higher rates of heart disease than other professions.

Most of these statistics came from before we started to turn the tide on heart disease. This was before cholesterol drugs and anti-hypertensives were mainstream, but when smoking still was.

Now, on the internet, I read about the burden of stress, anxiety, and depression doctors bear. It is no surprise, mental illness and its complications (i.e. addiction) seem to be an epidemic sweeping our country.

Why should doctors be immune? Especially, if we spend hours and hours caring for people with these diseases, is it no surprise some of it might rub off on us? You cannot vaccinate yourself against despair, loneliness, and disconnectedness.

Yet, We Are All Related.

I step away from the fence, feeling indebted to this long departed colleague of mine. Many, many things have changed in Medicine. Nonetheless, some things seem not to change.

Being a doctor is a hard job. It demands a lot. More than any one person can reasonably be expected to give. Yet, we do give, repeatedly and sometimes to excess.

The good doctor on that hill on the High Plains gave all he had to Medicine. It was sacrifice, yes, but I don’t want to glorify it. I will not say Dulce et Decorum Est Pro Medicina Mori.

Nonetheless, for a moment, I feel connected to a different kind of Medicine.

Not the Medicine of RVUs and production targets and treatment algorithms, but a deeper calling to serve humanity.

I’d like to think I can be doctor without sacrificing everything. But it is a delicate balance, and more often than not and I am too far one way or the other.

My eyes trace the line from his headstone to the Ghost Road in the southern sky.

At least, I think, I am not alone on this road.

Back to Work

I haven’t posted in a while. Not surprisingly, I have been somewhat occupied. Our new baby requires plenty of work, time, and love. Blogging hasn’t seemed all the important in comparison.

However, I am back on the High Lonesome, which brings with it periods of down time. This time is ripe for blogging.

Being back in the doctor’s role is an interesting transition from new father. Especially, after all the struggle over the last year and a half.

A Baby Brings Perspective

In some ways, I have a newfound acceptance of the failings of medical culture. All the pettiness, greed, and self-importance of many of the actors in a hospital are easier to tolerate, because the reason I show up is so much more important now.

Sometimes the work is its own reward. The times when I actually connect with a patient can sustain me – for a time. The rare critically ill patient who my team triages, treats, and transfers effectively can boost morale and help add meaning to the work.

Nonetheless, the reality is, most of any profession or job is mundane. Having a reason to go to work outside of paying off of my loans and funding my own diversions adds meaning to the mundane – especially when you are paid by the hour.

Knowing that my daughter is home and depends on me adds a certain nobility to the simple paycheck. It helps put a little shine back on the tarnished image medicine has for me.

Yet, on the first day of returning to work at one of my frequent work locations, I end up in my first meeting in over a year. Somehow, we are now having meetings….as locums.

I was scheduled to work and the ED wasn’t busy, so it didn’t turn out to be a big deal.

Of course, the main action item of this meeting was how to improve our billing and reimbursement. After only 3 years in practice, I am almost positive no other kind of meeting exists in healthcare.

This one specifically focused on improving critical care and procedure billing.

Good to be Back!

Other than this inauspicious start, the first day of the shift went fairly well. Going back to a familiar site was a good call for a first shift back. Weirdly, I seemed to actually enjoy being in the hospital.

The hospital had changed the way the local docs rounded in the hospital. This had actually improved communication and the nurses were asking me less questions about patients whom I didn’t know.

Finally, a change whose goal was improving patient care that delivered some results.

The first two patient’s were turfs from clinic for a DVT rule out and a CHF exacerbation. I quickly and efficiently ruled out the DVT. The CHF patient was known to me so the work up and admission to the hospital ended up being fairly straightforward.

Having wrapped up this work, I noticed a lull had set in. I went to the doctor’s quarters in a nearby house to rest and put some space between me and the hospital (it always seems to make the shifts go quicker). I felt good.

Watching some Netflix and making dinner, I waited to be called in. Around 11 pm, I got a call. An ambulance was out for someone who was found down and unresponsive.

An Actual Emergency

I find this chief complaint to be one of the most varied in actual cause. Benzodiazepine overdose, DKA, patient already deceased, sepsis, vasovagal episode, seizure – it could be practically anything.

In small low acuity EDs it tends towards the more mundane. Nonetheless, I headed back the ED and arrived right as the patient was being wheeled into the ED bay.

I recognize her immediately. She is a chronic respiratory disaster.

At 57, She already has end-stage COPD with multiple intubations in the last 12 months. This is, of course, coupled with right-sided heart failure. Shockingly, her kidneys are okay.

Her family has been told multiple times she may never come off the ventilator and she always has – so they now think she always will.

I know her to be angrily, vehemently, and obstinately FULL CODE, despite her terrible chronic disease and inability to care for herself at home.

She has had repeated blood transfusions for anemia which is of unknown source because her respiratory status is too tenuous for endoscopy. Not surprisingly – she also has terrible veins and recently finished a prolonged course of IV antibiotics through a PICC line (which I noticed sadly had already been removed).

“Oh, Shit,” I think to myself.

I look at her on the gurney. She is on a nonrebreathing oxygen mask. Oxygen is actually reading in the high 90s – remarkably good for her. But you can hear her audibly wheezing. Her chest heaves almost off the bed as she breathes in, and then her breath just slowly leaks out.

Her GCS is 3. Yelling, sternal rubs, nail bed pressure – nothing.

Getting to Work

We all get to work. An intraosseus line is placed in one leg – she gives no indication of being aware of a needle being drilled into her tibia. The nurses draw blood and send it to lab.

We give her narcan – she is on a large number of narcotic pain medications. Again no change.

I have the team set up for her intubation as her oxygen levels are starting to drop. Positioning myself at the head of the bed the intubation kit lays ready. I tell the nurse to push the anesthetic, then the anxiolytic, and finally the paralytic. She stops breathing.

Opening her mouth, I slide the laryngoscope into her mouth, visualize the cords, and slide a number eight endotracheal tube into her trachea.

We secure the tube, verify correct position, and begin to breath for her. All in all, it goes pretty well. The chest X-ray shows pulmonary edema, possible infiltrate, ET tube in good position.

Her labs come back, possible sepsis, blood gas shows a PCO2 of 124 prior to intubation. Methamphetamines in her urine. We start sepsis and influenza anti-infectives, give steroids, and get her ready to transport to ICU.

All in all, from arrival to transfer, we do this all in less than 3 hours. Not bad for a family doc in a two-bed emergency department 100 miles from the closest trauma center. Also, it is snowing, so the helicopters won’t fly – she has to go by ground, of course.

The Thrill of Being Present

As she leaves in the ambulance. I am feeling pretty good, alive. We just saved a life – for now. I just spent three hours completely engrossed in something pretty amazing – working as a team with people who gave a shit on something important. It can be intoxicating in small doses.

I like critical care. I like obstetrics (though I don’t deliver babies non-emergently anymore). What I love is the focus on the task at hand. The power of a small group of people fully engrossed in what is happening in that very instant can be amazing.

Both critical care and obstetrics demand this kind of focus. We should all strive for that kind of focus in all aspects of our practice. Sadly, this is difficult given the seemingly coordinated effort to destroy it going on around us.

The High Fades

After a rest and a drink a water, I walk back to get some sleep – it is 2:30 AM after-all. On the walk, I can’t help but feel a tension between the excitement of caring for a critical patient and the ethics of how we spend healthcare dollars in this country.

How many intubations is too many for one person? Is it ethical to repeatedly intubate and, God forbid, actually code someone who lives on death’s doorstep every day?

Does one person have a right to unlimited medical expenditures to prolong their life? How many childhood vaccinations could that cover? How many addiction treatments, or early parenthood interventions could we pay for?

The methamphetamine in her urine and her 3 different narcotic prescriptions are evidence of a life of great suffering. That suffering predated her current illness. Indeed, the smoking and drug use which caused it were likely attempts to numb that suffering for decades.

Is it ethical because these are the patient’s stated wishes? Or are we just hiding behind a weak patient autonomy argument so we don’t have to wrestle the suffering we witness – and prolong.

The things we do to save a life, needles drilled through bone, tubes into bladders and lungs. It would be torture in any other situation.

I feel guilty about how excited I was afterwards – even though I saved her life. I also kind of feel guilty about that…

When is it too much? When is continuing to torture someone to keep them alive, and suffering, unethical – even if they demand you do it?

Are these even questions we can ask in American Healthcare?

Recognition

A week later I get an email from our new ED medical director:

“Doctor HP,

Great job with the care of patient #1234567 in the ED last week. Your documentation of the intubation and critical care time was excellent!

Sincerely,

Your Medical Director”

I sit back and sigh, good to back working again….

A Note of Gratitude to Medicine

The end of the year is always a time for reflection.  The darkness leads to more time indoors, more time with our thoughts, and often with our families.  Reflecting on this difficult year is a strange exercise for me.

A Tumultuous Year

My wife and I have passed the one year anniversary of my daughters birth and death.  Moreover, I am now more than 6 months into my new gig as a traveling critical access doctor.  Life has started to settle into a bit of rhythm. 

After all of the grief and upheaval of the last year, simply living a relatively normal life can be rather unsettling.  I seem to even seek out problems or reasons for dissatisfaction.  I have a bit of a restless soul – a blessing and a curse.  

For one, the holidays seem to be a negative trigger for me this year. 

I always struggle from the time the clocks change to the first week or two of January.  The loss of light affects my mood for the worse.  Prior to last year, I had a great ambivalence about the holidays – neither a grinch nor a lover of the season. 

The Shadow of a Loss

That being said, last year’s holiday season was not a good one for our family.  The holidays came very quickly on the heels of our daughter’s passing and I was on call for a good bit of both Thanksgiving and Christmastime.  

With those memories so fresh, this year’s holidays are hardly buoyant.  Sure, the pain is not as fresh and does not burn quite as bad, but its shadow stills falls on the season.  

Living through this holiday season is like walking through the burnt-out shell of an ash-covered family home.  The shock and wailing pain of watching the flames tear everything apart has past.  Nonetheless, an eery sadness lingers over everything. 

To keep myself from falling into a hole of self-pity, I have taken some advice to actively practice some gratitude.  God knows I have plenty reasons not to feel gratitude, but I also have plenty reasons to do so.

Giving Gratitude a Chance

Even last year, my wife and I took time to be actively grateful for the arrival of our daughter, even if her presence with us was far too short.  She taught us a great deal and the heart cannot be overfull of love.  

Finding gratitude about the current state of medicine and my role in it takes a little more effort. I have written a lot about my experience in medicine and life over the last few months (and it hasn’t all been rosy).

Yet, I also remember the ones and things we love are often what can hurt us the most.  My relationship with medicine is much more complicated than it once was.  

I struggle to accept the imperfections of a system charged with healing yet is highly profit driven and largely inhumane. 

This system charged me a steep entrance fee.  The cost comes in actual dollars but also in time and stress and tears.  In the end, I felt expendable.

Yet, I also have to remember the care our daughter received in that same system.  I cannot forget our neonatologist sitting in front of our house with us as we held our daughter without tubes or machines for the first and final time. 

Humanity does still course through the veins of our healthcare system, even if the system neglects it at every opportunity. 

Nonetheless, My Privilege is Great

Doctors are a pretty privileged lot, all things considered.   I don’t mean to minimize my own or other’s distress at the current state of affairs.  On the other hand, I see how my situation may have played out very differently for someone else.

Few other careers exist where you can quit your job, move to another state, and have to turn down work immediately.   That is how it worked out for me. 

I simply showed up and had my choice of work location and practice type within my speciality.  Not only that, but I have been able to improve my worklife balance with an acceptable sacrifice of income.  

Physicians skills are in such need that not only was I able to find a different job, but a completely different way of working.  Hard to complain. 

Medicine giveth, and medicine taketh away.

Work isn’t Everything

Even more importantly, medicine had given me wisdom.  Caring for people who were very ill or had suffered great loss or trauma gave me access to life’s most difficult moments.  Few other professions allow for the gaining of such wisdom without personally suffering those blows.

Learning how to help guide people through their struggles led me to read books and literature I never would have read otherwise.  This knowledge was invaluable when our daughter was born.  I didn’t have a how-to guide, but at least I knew the big ideas.

Most importantly,  I had learned the value of connection.  When our daughter was born, our gut reaction was to circle the wagons, raise the drawbridge.  My patients had taught me this was not the right move. 

Love and loss must be shared, inextricably linked as they are.  We called friends and family and offered for them to come to meet our daughter.  To be present with us in a difficult time. 

Without exception, the responses we received were full of gratitude.

“We are honored to come,” was the common answer.  

In our moments of grief, this might surprise us, but it shouldn’t.   Wouldn’t all of us respond the same way if someone we loved extended us the same offer?

Moreover, the decision has paid great dividends.  To those who met her, the people we love, our daughter is not simply the nameless baby we lost.  She was a person, has a name.  We can talk about the shape of her nose, or her special little movements with so many people. 

Having her in more people’s memories does not just preserve her memory, but means she was even more alive when she was here.  Hell, we even have a social security card for her.

It is the caring for patients that taught me this knowledge before my family needed it.  In the end, I am still thankful for medicine.

“When you are sorrowful look again in your heart, and you shall see that in truth you are weeping for that which has been your delight.”

― Kahlil Gibran

Cold and Dark Return to the High Plains

moon over the snow

I walk the outskirts of town, the cold and dark are everywhere.  The darkness has returned to the High Plains.   From daylight’s savings until the return of sunlight becomes perceptible again in January are the low parts my year.  I don’t mind the cold, but I miss the light.

The cold can be clarifying tonic on the High Plains.  It is not suffused with the dampness of Eastern cold.  It is a freeze-drying cold.  Bracing is the word for it.  The darkness can be disorienting, but the cold wakes you up – keeps you focused on the fact you are still alive.

Moonlit Night on the Dniepr – Arkhip Kuindzhi – 1880, Tretyakov Gallery, Moscow. Public Domain.

Tonight is cold and brightly dark, punctuated by the shine of a waning moon, though still nearly full.  It has been a tough past few days on call on the High Plains.  The darkness and the holidays bring out dysfunction and mental illness.  Without a clearly lit path, people quickly wander back into their own darkness.

A razor-thin slice shy of freedom

For the second time in 12 hours, I am reapproximating the flesh on the left forearm of a man in chains – offenders as the guards say.  The same man. Two cheeked fragments of a razorblade did the work, the second one not found in time.  I had known he was serious about wanting to die.  While stitching up the wound when it was only 4 inches long, he had calmly made small talk.

Disinterestedly watching me sew his numbed arm, “I guess it is harder than on the movies.  In them it is one smooth slice and they die quick.”

I pulled my running vicryl suture, the fatty subcutaneous tissue tightening. He didn’t flinch – a good anesthetic field.

“The body is designed not to die,” I replied. “The body wants to survive.  I might not be able to get your tattoo back to what it was before.”

I ligate an small oozing vein, luckily for his blood volume, he didn’t know the vital vasculature is quite a bit deeper.

“That’s okay.  It’s just their to cover the name of a girl who isn’t my girlfriend no more.  I don’t suppose you can tell me this, but what’d I do wrong?  Where’d I miss?” He asked.

“You’re right, I can’t tell you that.”

That was the first time. After stitching his arm back together I thought about the safest place for him.  Prisoners don’t have a lot of options.  A locked unit for prisoners in the county hospital 2 hours away?

The prison guards assured me he would be watched and would have access to telepsychiatry within several days.  All the options sucked, this one seemed as good as any other. I discharged him back to their care with signed orders for follow up. I even asked them how they were going to keep him from ripping it back open – they had had an answer.

just looking for some peace

Within 12 hours, he was back.  The wound twice as long, but only minimally deeper.  Still no muscle or large vessel damage.  Killing yourself with a half-inch long piece of broken safety razor is not for the faint of heart.

Shit, I think.  I should have found harder for a different solution.  Clearly that didn’t work.  Was I cavalier with his safety?

Me: “So, how did you get another razor blade?”

Offender/Patient(O/P): “I had another one hidden.”

Me: “Where was that?”

O/P: “Well, I can’t tell you that, its privileged information.”

He sprouted a mischievous grin.

“Was it somewhere sensitive?” I pushed.

“No.” He seemed ashamed of the implication. “I had it cheeked.”

shit, he had a back up plan…

A different facility would not have been any safer – he really wanted to kill himself.  Who tries to kill himself and holds something back, just in case he fails?  Someone who knows life is worse than death.

Me: “Well, why do you want to die?”

O/P: “I just want some peace. I’m tired of my shit getting fucked with, of me getting fucked with.  I am not affiliated, so everyone fucks with me.  I just want to be left alone to do my time.”

(Affiliated, if you are not familiar, means not in one of the prison gangs)

Me: “How much time do you have left?”

O/P: “Well, I am up for parole soon, but I don’t have much hope for getting out.  My latest possible release date is 2024.”

Me: “What would it take for you be able to want to live that long?”

O/P:  “Just to be alone, in peace, doing my time.”

Me: “Like solitary?”

O/P: “Yes.”

I place the last 3-0 prolene horizontal mattress suture – for strength, just in case he has another back plan.  Well-approximated, I muse.

the lonely moon

Sitting on the hill, I take in the pale moonlight glancing off the water tower.  It sands in front of the red warning lights of the wind turbines on the distance ridge, which are blinking in unison.

The guards placed O/P into a prison van and took him to the state penitentiary’s system infirmary.  He would be kept shackled the entire time, to prevent a similar incident.  Likely shackled to a bed, with minimal to no freedom of movement. Additionally, the guards assure me he will have urgent access to mental health resources.

I don’t know what this man did to be in prison.  The prison nearby holds serious offenders.  He likely needs to be in prison to protect the rest of us.  Whatever he did was probably enough to sacrifice his right to freedom.

I can’t help see the irony in his desperate attempt at finding peace.  Trying to free himself from his current version of hell, he lost the last of his freedom.

I take in the peace of the night.  The moonlight reflects off the recent shallow snowfall.  My breath freezes in the air and slowly drifts off, without any perturbation. I think about Johnny Cash’s classic – Folsom Prison Blues.

Well I know I had it coming, I know I can’t be free
But those people keep a movin’
And that’s what tortures me

Shit is fucked up, I think to myself.  I start to slide into my cerebral self-flagellation.  Am I supporting the prison-industrial complex?  Am I profiting from it?  Who am I kidding?  Continuing to breathe in this world necessitates a tarnished soul.

I watch the bank of red lights blink.

O/P seems to have accepted his sentence of time.  I cannot and do not want to pretend he is a gentle man or a kind man.   True compassion doesn’t require a made- up story to make the person worthy of it.  He probably needs to be where he is.

Nonetheless, I do wish him some peace and hopefully it does not require his death.

 

 

 

 

What Could We Have Done Better….Part 1

Everything that comes after in this blog will be informed by this experience.  So, I feel that I have to start with it.

Scene: My last medstaff meeting in my previous job after making my resignation official:

One of my partners: Can you elaborate on why you are leaving and what we could have done better to help keep you?

Me:  I have found that emotional intelligence is not valued here.  I feel less human because of the year I have spent here.

Same Partner: That is very sad.

Other partner: Can you elaborate on what you mean by that?

Me(tears starting to form):  Not right now.

Later that day I was told by our clinic manager that all of the medical staff told him that they had no idea I felt that way.  I felt my point about emotional intelligence proven.

Stepping back a few months…

I had been in this practice for almost a year and we were expecting a new baby.  Because of how tight the call schedule was, I had only opted to take the 2 weeks off around the suspected due date.  I had repeatedly asked the administration and my partners to arrange for back up coverage because things often do not go according to plan with babies.  Things did not go according to plan.  My wife was induced at 37 weeks (3 weeks early) for polyhydramnios.  Our beautiful little girl was born and required significant resuscitation, ending up in the NICU on a ventilator with a feeding tube.  I called and told my partners not to expect me back until further notice.

The news didn’t get better.  She failed extubation twice, she didn’t have the strength to swallow or breath without mechanical support. We never got a diagnosis, which wasn’t surprising or upsetting.  Diagnoses rarely help patients as much as they do doctors.  A rose by any other name would still require ventilator support.

We started hospice/end of life discussions with our neonatologist.  That same week my partners called to see if I could cover call on a Saturday because “no one else was available.”  Not like I had anything better to do….(I refused).

We took her home on hospice.  She was extubated on our front deck in the sun and she passed peacefully.  It was beautiful, and terribly, heart-wrenchingly sad.  She was three weeks old.  We cried, a lot – we still do.  We a took a week and scattered her ashes on a sacred mountain.

Rachel Weeping
Photo Credit: By Charles Willson Peale – Philadelphia Museum of Art, Public Domain, https://commons.wikimedia.org/w/index.php?curid=7365050

I decided I should ease back into work.  It had only been 4 weeks since she was born, less than 2 since she passed.  It was probably too soon, but I figured that I would have to sooner or later and easing in would be best.  No one gives you a guidebook for navigating the death of your newborn child.

I felt that I had communicated that I wanted to ease back into work.  My partners felt that it was appropriate for me to take back on my full call burden.

This included the following: 120 hours of ED call within 7 days including Thanksgiving.  The 72 hours of call before 8 AM on Christmas morning, and the 24 hours following Christmas. I was still the f***ing new guy, apparently it didn’t matter that I had lost a baby with whom my wife and I were supposed to spending our first holiday season, but weren’t.

When I tried to back off and protect myself, here is a greatest hits of things I heard:

—–

After effectively being told that it would be too difficult to find someone else to take my call:

Me:  You know, I still have over 30 days of paternity leave I could take.  I don’t have to be here, I came back to help.

Partner:  Well, it would have been easier to arrange coverage if we could have planned for it.

——

CEO in one conversation: We want to support you however we can, but the other docs are already run pretty ragged right now.

CEO in another conversation: We may not always do the right thing, but our hearts are in the right place.

——

Same partner as above in a conversation about me possibly switching to do just hospitalist/ED work for a time: I would hope that you think about the burden it would put on us to cover the outpatient work if you were to do that.

what could we have done better to help keep you?

I guess you could have just been the human beings and caregivers you say that you are….