It’s been a while

I’m not sure it’s a great sign I’m posting here, but saw that I still get hits and comments so I thought I would. Having logged in after a long time off, I see that I have hit 50,000 reads. That blows me away. Thank you. I hope it has helped someone.

Unfortunately, the emails people sent me got erased so if you never got an answer to some burning question from me, send again. I know I used to get a lot of mails from pre-meds and med students and the like, wanting help on planning their lives with the crazy. I’m totally happy to help, for whatever I can do, but if you wrote me and didn’t get an answer, just write again.

I’m now working in an underserved community, doing womb-to-tomb medicine. It’s as good as it gets in the medical world, I guess, as far as people being a little more right-brained. One of the docs even gave a talk about his own struggles with the crazies, which seem to be much the same flavor as mine. It’s funny, I so admired him for being able to do that, but now every time I see him, all I can think of is that, and I know it’s just not a good idea.

Still doing the 80 hour weeks, though. I moved, and here they have seasons, and their winter was oh so cold. I hate the feeling of layers over all of my body, all the time, and always being cold. The days don’t shorten that much and I did ok, and now the days getting longer have made me a little funny – horny and too loud and overly energetic. I hope it will be just a little funny though. They seem to like me ok here, and I wouldn’t want to blow that by going all nuts. The one thing I am looking forward to at work is that they may let me run a DBT or some other kind of crazy girlz group, though I’m a little hesitant because the way I would approach things (melodramatic legend, myth, and metaphor) seems so far removed from the socioeconomic language of the patients here, and I do enjoy the palliative care stuff. It feels like a kind of holy midwifery to me, though I do hate the power of making people make decisions and messing with the course of their lives.

I still hate delivering babies, though. I can’t remember if I’ve written about that before or not. It always seems like I’m ushering in 80 years of suffering.

Things, on the whole, have stabilized, mostly due to medication, but of course, there is always the price of blunting. And getting fat. One of the meds, the one that makes me nice and cuddly, makes it nearly impossible to concentrate long enough to write. I have to keep away from thinking too much, and I do miss my sense of feeling, but the working so hard and long is good for keeping thoughts and dreams away. The patients I work with have often had such wretched lives that it helps me be grateful for what I have, for the blessing of being able to settle into a boring, mildly dissatisfied middle-class life. And that depth of experience, well, yeah, I do sometimes miss it, and do sometimes know that I’m walking someone else’s path, and have those grave feelings of not doing what I was put on this planet to do, and fear of being sent back next time ’round to do it right. But fortunately, modern pharmaceuticals can mostly keep that away.

So I’ll leave you with this.

for prodigal read generous
–for youth read age–
read for sheer wonder mere surprise
(then turn the page)

contentment read for ecstasy
–for poem prose–
caution for curiosity
(and close your eyes)

Thanks for reading.

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As I said…

Crazy doctors are better for crazy patients.

Other than that, I’m here, the new med seems to be ok, I mean, at least I function, but has absolutely shot my writing ability and drive. The words don’t fly, I don’t have the motivation, the little voice doesn’t talk. Trade-offs. I’m coasting through picking up odd jobs.

In response to a comment on an older post, I wrote this:

Since last posting, I found a different psychiatrist, and after a few more med attempts, landed on one that works, and I haven’t been back to see him since. And hopefully I won’t. The difference was immediate, the guy was … not great, but PROFESSIONAL. No mind fucks, no innuendo. I don’t really understand what exactly happened with the one before, I think in retrospect a lot of the drama and trouble was not my fault. The perspective of distance from the situation has let me see more clearly and stop blaming myself for someone else’s problems and emotional shit. I have not ever been in any kind of relationship like that before. The best explanation I’ve heard so far is that somehow we crossed in past lives or something. It is just one of those things.

Now that I am reasonably well medicated, all the crazy just falls away. It’s so strange.

Sorry for anyone waiting for me to write or anything. It’s just not there anymore. I’m a little sad about that, but at least I am back among the living.

The Medical Paper Gown

I recently got an email from a reader that included this bit:

I just left the hospital last night after a small cut needed 7 stitches. Nothing big, just obviously a self inflicted wound. The nurse tried to force me to put on a gown in the middle of the ER while no other patients were wearing one. I realize now it was to see how many other cuts I had. She yelled at me when I refused.

Which led me to realize that a good topic for a post would be “What’s up with those hospital gowns?”

About gowns in general, I assume the reader is in North America.  The whole gowns thing is an American thing. Sometime in the 1950s, some efficiency expert decided that doctors could work faster if patients were all naked when they came in the room. But naked seemed too awkward, so the NOT-awkward paper gown was invented. And they tell you to get in it before the doc comes in, presumably to save time! There’s no real medical reason. Most doctors today probably don’t know this. Incidentally, there’s tons of discussion online between medical professionals about what is more sanitary/cheaper/classier – paper or cloth gowns, but no one seems to question much the whole necessity of the things. Check out this article, and don’t miss the comments! They go over and over when to gown, what kind, how to put it on, but NEVER ask why to do it at all.

Nakedness/gowning never caught on in the rest of the world. I suspect this might have to do with cost of either disposable gowns or laundry. I’ve never worked anywhere where those gowns even exist. Our ER has pajamas for people who come in covered in blood or whatever – but they’re just pajama pants and button-up shirts with a hospital logo. There are robe-type tops for people who are having heart attacks or something and might need very quick access to their chests…but nothing like the American hospital gown (except in labor and delivery, and those are also cloth nightgown type things and everyone brings their own clothes anyway).

So, when the reader asks, “Is this normal protocol for a forearm wound?” I have no idea. For someone who finds him/herself in that situation, what I’d recommend doing is just saying Ok to the nurse, and not changing. I seriously doubt anyone would notice.

I personally don’t think that any time saved by undressing a patient beforehand is worth causing discomfort/awkwardness. Every country I’ve worked in other than the US seems to agree. In most of the world, the standard practice is for a patient to come in the room and sit down and talk first, and then move to the exam table.

If we are on the subject of medical culture, I’ve also found that medical office rooms look weird in the US – most other places, the room is divided into the office part and the exam part, with a curtain or screen around the exam part and a locking door. The doctor sits at a desk, and the patient on the other side of the desk at first, moving to the exam table only later. It’s like walking into basically any other kind of office in the world. I have no idea what’s up with the weird rolly chairs and patients sitting on exam tables there.

To examine a patient, AFTER we’ve discussed what’s going on, we ask him or her to move to the table if necessary; if I only need to check their throat or something, I’ll just do it in the chair. No getting naked. They go to the table, and I either put my hand under the shirt or pull it up to listen to heart and lungs, pull pants/skirts down to the hip and shirts up to the ribcage to examine a stomach, whatever. It is NOT the world standard to do the whole gown thing or ask a patient to strip down to begin with. I guess sometimes, if I need to check feet or something, I wait a little for someone to take off their shoes…but I doubt it’s a significant amount of time. Not worth having every patient come in with shoes off.

I don’t do a lot of gynecological exams, but usually the standard is to just undress from the waist down, or pull a skirt up, and use a regular sheet to drape over the patient. I don’t give instructions, so some women wrap themselves with the sheet more like a towel after a shower, which is fine with me. If I know that the complaint is not likely to require a full internal exam (likely a yeast infection or something), I usually don’t even do this, I just have her lie on her back and slip her pants down to her knees and look like that while I stand at the side of the table. I think it’s less invasive if I stand there than between the legs, and it feels better to have pants around your knees than totally off. I do not use stirrups at all, just have them put their knees on the table and spread. I’m not even sure if most of my exam tables even have extendable stirrups. I think that the ass-hanging-off-table and feet floating in the air in stirrups is a much worse feeling than just lying down on the table.

Of course, I’d probably fail a medical school exam if I were seen doing this. And I don’t often do a really comprehensive gynecological exam where I need “full access.”

Other times I can think of where I need more exposure is during an orthopedic exam if I think legs might be different lengths or I want to check for scoliosis (both can be done in underwear or even with pants pulled down a little and shirt off, bra for the ladies), a full skin exam (which can be done in parts), rectal exam (which I do by just lowering the pants as little as possible while the patient lies on his side with knees bent, which I think is better than bending over, but if you’ve been through it, let me know if I’m wrong). Believe me, it feels better to have your underwear half pulled off or lifted than to sit around naked in a gown.

While we are on the topic, another practice that seems uniquely American in my experience is for the doctor to be running between multiple exam rooms at once. I’ve not seen another country where patients are briefly seen, asked to undress while the doctor leaves and sees another patient, and then returns. Most doctors have their own office where they sit all day, and patients enter, finish everything, and leave. Offices are therefore more personal as well, because they belong to a specific doctor and all of her shit is in there (well, especially if you are like me), not a clinic where doctors are bouncing all around looking for open rooms. I can’t wait to finally be settled in my own permanent office, where I can paint in warm friendly colors, and put in nice furniture and curtains and normal lighting rather than overhead.

One more thing: chaperoning! I personally hate this. My family doc is a man (I used to have only women doctors until I went to medical school and then realized that 1. it didn’t matter, and 2. I would be pretty pissed off if someone didn’t come to me just because I was a woman) and despite knowing me for years, he lately has started calling the secretary in for even simple exams.

I do understand why and all that, but on the other hand I find it kind of offensive – like, does he really think I’m going to sue him? It bugs me every time, messes up the basic trust of the relationship. And of course, it makes me wonder that if I weren’t a psych patient too, would he do it?

Thoughts? Do you want the chaperone or not?

I was so proud of her

I saw a patient the other night with a ton of psych meds in the ER for something unrelated. She was neither young nor old.

(Incidentally – definition of “a ton of psych meds” = more psych meds than me.)

And she was totally normal. If I hadn’t read the list of meds, I never would have known by how she looked, how she presented her pain, how she talked or reacted in conversation, how she was dressed, how she handled the interactions with everyone. No anger, no speech impairment, not slow through a drug haze, not hostile, not overly passive. Nice. Normal. I never would have known.

I always worry that psych patients are always so obvious to doctors after a few minutes, even if they function well or are only mildly ill, that I must be too, that it must be obvious to anyone who treats me. But she wasn’t. She gave me hope. And I was so proud of her.

But of course, I couldn’t say anything.

Self-harm from the doctor’s point of view

Edit added at the bottom.

First of all, this is going to be detailed, and if it might upset you, please do not read.

I’m going to leave the details of the story pretty generic to be sure to protect patient identity, though it was a pretty typical self-harm story, I guess, the kind that is seen in emergency rooms ’round the world every shift.

As I said in the last post, the subject of scars has been going around the internet, how people feel about them, having them for the rest of their lives, after they have stopped. So that was very much on my mind when she walked in – that I wanted to leave her the minimal scars possible, so that when she gets older and better, she won’t be disfigured.

I have no idea what her actual psych problem was. She was quiet and pleasant, hardly spoke, probably some depressive affect in there. She was brought in by her mother, technically being a minor. She looked much younger than her age. She had, by the record, been in a few weeks before for the same thing.

My only hint as to what I would find was the fact that her arm was heavily bandaged from the hand all the way up to almost the shoulder. I think (though I’m not basing this on anything) that more common is maybe 5-10 cuts on a forearm.

I took her into the stitching room and set her on the table, ready to unpeel the million layers some nurse somewhere had wrapped on. I asked her her name. She made one request before I started, was very childlike in speech and mien: “I don’t want my mom to see it.” The mother was there, knew full well what had happened. I thought it was actually a sign of maturity, wanting to deal with her problem herself, to not upset her mother. I was fine with that, I mean, if she’s old enough to request, and to be in this kind of trouble, then she’s old enough to deserve some privacy. But then some ER manage walked through and heard and flipped out that she is a minor, the mother has to be in there. I got kind of pissed off at that. My patient, my call. I now wonder if I was mad for the sake of her autonomy, or for having my authority undermined.

So I sat the mother down in the room and closed the curtain around the table, leaving the mother “in the room” but not visible. I started to unwrap. The nurse who had dressed it somewhere had slathered TONS of iodine all over everything.

It was a tremendous mess of dried blood, fresh blood, and the fucking iodine. (Which is not shown to prevent infection any more than washing with saline.) It was impossible to work. We had to wash it all off. She didn’t want to come over to the sink, so I let her lie with her hand and arm hanging off the bed and started to wash with bags of saline. Plenty of the wounds were full of clots and dried blood, some were actively bleeding, and the iodine was everywhere.

And as I unwrapped and cleaned, I realized the extent of what I was seeing.

From what I had read on blogs and their accounts of the emergency room, I assumed that self harm was usually around 1-10 cuts in various shapes or lines, usually on the arms.

This girl had perhaps fifty or sixty slashes to the subdermis, about 5-7 cm long, in parallel, parallel to the wrist and elbow creases, on both the wrist and back side of her arm. She went past the elbow, halfway to the shoulder, and some of the cuts higher up had actually had skin removed. They weren’t just slices, but rather ellipses – but not the lines of ellipses, ellipses with the skin inside removed. I couldn’t imagine actually sitting there and doing that. Plastic surgery creeped the hell out of me, the lifting of skin from its bed. She must have done that alone somewhere.

Washing up took at least half an hour, digging out the mess in each wound. I told her to tell me if it hurt, or if there was a spot where she’d rather clean herself. She did but ultimately was too tired or depressed to do much of it. By the end, my feet were soaked in fluids and blood. I hoped she didn’t have any blood-borne disease.

Then just finding enough Dermabond was a nightmare. That shit is expensive, so I had to raid the whole place to find some – each cabinet had one or two vials only. This also took a long time.

Just for public record, since I guess many people might not know this, stitching or closing a superficial wound is not to stop bleeding or prevent infection (closing actually increases the chances of infection). The idea is to bring the edges of the wound as close as possible for the smallest possible scar. It is a cosmetic technique only.

Putting it back together was another story. There wasn’t enough skin between the cuts to really stitch anything, there was no room to land a stitch that wouldn’t tear. She was sliced to ribbons. The The hand ortho guy decided to try to glue them. Some of the defects were clearly not fillable and would have to be left open, invariably leading to horrible scars. I kept thinking about when she was older. In just one cutting episode, she’d probably achieved arms that some people achieve in a decade.

I also wondered: it seems like most forearm cutters make slices in that direction, in a “slitting the wrists” way. Unfortunately, to me (not sure on this, but it seems like) that seems like the way that goes exactly against Langer’s lines, probably the worst way to scar, because every time you flex or extend your arm, that skin is getting pulled. It probably is better to do with the line.

We started gluing, but discovered the same problem. You couldn’t glue one closed without pulling the one next to it. There just wasn’t enough to anchor anything to. And to glue, everything has to be dry. Blood from upper wounds kept dripping down into the field. It was just not possible.

The plastic surgeon was called; maybe there was a special trick here that we didn’t know. No, she said. Leave it alone, bandage it up. There’s nothing to do here.

So we wrapped the girl up and sent her on her way. I made sure to tell her goodbye, using her name. Throughout the whole thing, I kept thinking of people’s stories that I have read, about the various versions of both good and asshole ER docs who have stitched them up, and I didn’t want to be this girl’s terrible story. She didn’t seem too chatty, so I didn’t push, just asked her often if something hurt, didn’t make a big deal of it. Tried to treat her like a person. Offered to try to set things up so her shirt wouldn’t get wet or ruined.

I wanted to tell her this, but I didn’t think her mother would be too happy, so I didn’t. I don’t feel bad about putting this out there, because it is a basic harm reduction principle, which I believe in.

Instead, I’ll tell all of you now: I know that it is a hard thing to stop. I know that nothing I can say will stop you, and that sometimes, that is the safest kind of relief available. I get that while you are doing it, you are kind of in a trance, and probably not thinking too clearly. But you will have to live with the scars one day when you are better. Try to space them so that they can be aesthetically closed. Try not to cut in areas where the skin, during natural movement, is pulled – this will widen your scar, instead, go with the grain of the skin, in a place where it isn’t pulled tightly. Try to stay as superficial as possible, the less deep you go, the better it will look.

We might consider some of our scars, both physical and emotional, badges of pride. But these are different, because they are so public. Someday, you will feel better, and you won’t want to be reminded of such a bad time every single day.

* * *

Edit: a point I wanted to make originally, and somehow forgot. I wanted to explain how I felt toward her, what she evoked in me.

I didn’t feel pity or sorry for her. I didn’t feel annoyed at her like a lot of medical personnel do at self-inflicted problems (and this means all kinds of lifestyle problems, not just psych). I didn’t overly “feel her pain.” I felt, at the time, that it may as well have happened by falling through a glass door or something.

This might come off as cold, but I was glad. I think this is actually a sign of medical maturity, I didn’t have any superfluous judgments (good or bad) about who she is/was, what she did, etc. She needed medical attention, period. Also, my own life and pain didn’t carry over in any way to how I felt toward her, positive or negative. She was just another case. And that was good.

As to a more thorough psych evaluation at the time, I’m sure I could have pulled more out of her if I had tried, but what would be the point? Obviously, plenty of people with lots more experience than I have are involved with her and not succeeding. Everything about her said she didn’t want to talk. She wasn’t silent in a “just-ask-already” way. There were no signals that she wanted to talk, she didn’t make eye contact, nor actively avoid it in an obvious question-seeking way. She was just silent, alone in her thoughts. Right to privacy is important. This gets lost in psychiatry a lot – especially after suicide attempts. Every doctor that comes through thinks that he or she has the right to ask, “Why did you do it?” They don’t. She doesn’t have to be “grilled” by me just because I happen to be treating her arm.

If I could have gotten the mother out, I might have tried to talk more openly. But I knew nothing about either of them, nor of the relationship between them, other than that the mother seemed kind of abrasive and gave me the impression of looking for someone to blame or sue, so I didn’t want a complaint later about how I told her daughter it was ok to cut. There wasn’t enough context, though, for me to be sure. Maybe it just sucked to be in the ER at that hour and she was tired. Neither spoke much. I only asked about what she used, to think of things like infection and tetanus.

Talking more during the hour I spent on the wounds wouldn’t have been helpful. It would have been for my curiosity or to satisfy my need to “help.” As much as we want to “help her,” she doesn’t have to justify or explain her injury any more than someone with pneumonia does. And I’m glad I didn’t feel an overwhelming need to ask or try to “empathize” or anything else, for any reason. I treated her with respect, like any other patient, and I am proud of myself for that.

Another psych patient. Could the signs be any clearer?

Another psych patient just fell on me last night. (Not the two other cases I didn’t write about.) We had split the night up and gone to bed – two hours and twenty minutes for each of the three of us on call. Two patients came in on my watch with abdominal pain. One was seriously psychiatrically ill.

He knew none of his medicines except for valium, which also was the only one he brought with him. (I actually can understand this; in an emergency, I’d definitely pick the clonex over just about any other drug.) His pain wasn’t really probably that serious, but his anxiety levels and panic caused him to pace around screaming, “I’m dying! I’m dead!” Fist pounded into wall. “Give me something for the pain!” He had a bed, but didn’t want to stay in it. He was doing the exact thing I described here. The nurses and staff were sick of him, especially since at 3 AM, most of the ER was sleeping and he was disturbing other patients. It would have been easy for me to get annoyed too, but I couldn’t, having written what I wrote just days earlier.

Everything about the story and exam suggested nothing serious. When talking to him calmly, he calmed down considerably. Touching his abdomen, even deeply, caused no obvious discomfort as long as I kept talking to him about something else while doing it. He had taken so much valium at home that I was hesitant to give him a narcotic, even though I did believe that he was in a lot of distress. I explained that to him. I thought that the thing that most would help him would probably be to give him a little more valium, maybe even IV, but I didn’t. I didn’t know how much he took regularly; he said he had taken 40 mg at home. He didn’t seem calm at all, so I figured that was just about maintenance for him.

In the hospital’s infinite wisdom, the psychiatric hospitalization discharge summaries in the computer are blocked. I couldn’t see what he was taking other than that (thinking along the lines of drug ileus), or what much of his problem was. An old medical summary had PTSD in there, but also mentioned a psych evaluation that had included episodes of psychosis under stress, borderline IQ. Whatever. All I wanted to know was what meds he was on.

The thing is, since I was already up, and not really feeling safe about giving him serious pain relief, and the nursing staff was going apeshit, I decided that it was time to try a “non-pharmacological pain control” mechanism, the kind of shit you learn about in the touchy-feely medical lectures, but never actually have time to do, and don’t believe will work anyway. I went over to the bed, stood at the head, put him back into bed, and I actually dropped the head of the bed down to put him below eye level for me. I always tend to walk in and the first thing I do is put the head of the bed UP so people don’t feel so helpless, and because it’s weird to me to talk to someone not on eye level, but this time I wanted the opposite effect.

I decided I was going to try something I’d never done before. I was going to do like the ER docs do. He was still yelling to “do something, I’m dying.” I summoned up my most authoritative “doctor” face and posture (and believe me, that gave me a little internal laugh), and instructed him to lie very still.

I examined his abdomen again very slowly, even though I had done that just 15 minutes before. I told him that nothing had changed, that everything was fine. I kept one hand on his shoulder, firmly, as I spoke. I told him that even when I went to work at the station, he was in a bed very close by, and I was keeping one eye on him to make sure nothing would happen.

To my utter amazement, it worked.

Anxiety and pain are funny, linked phenomena. People regress when they’re scared, need someone to take charge.

Unfortunately, when the morning surgeons came on, they decided that they couldn’t communicate with him well enough to rule out a serious problem without a CT. So he got a heavy dose of radiation. I never would have ordered that, especially given the whole history of the pain.

Damn.

* * *

I guess the lesson of this is for me is that there is a time and place for me to take on the authoritarian role. To speak very certainly, not explain options, just tell the patient that something is fine or not, and what the next step is. “I am now going to send you straight to x-ray,” without explaining why.

Usually when I do a physical exam I talk through it, while I’m doing an abdomen, I say as I move my hands around, “There’s the liver area, look, it’s not tender…and now let’s see about the spleen.” I also note every normal finding as I do it, because a lot of people think the worst. For example, when the doctor listens to your heart, really most of what they check is the valves only. A heart having a heart attack most likely sounds completely normal. It’s my little personal routine, as I move the stethoscope from spot to spot,  to say in between, “Everything sounds good.” This is a fairly meaningless statement, because plenty of hearts with problems sound fine, but still, it seems to me the considerate thing to do. I’ve never had a reaction other than relief or gratitude when I say this.

I also think: after all, it is the patient’s body, not mine. Just because I am trained to know things about it, to extract details about its state of health doesn’t mean that I have the right to know something about it that the patient doesn’t.

Incidentally, I also explain why I ask a weird question when I do, one that might seem irrelevant.

I do this because I remember as a kid, or not even a kid but a college student, the physical exam being so mystifying. What the hell were they doing? What could they tell? Why were they sinking their hands into my stomach? What did they hear in my heart?

But I didn’t do that this time. Instead, I examined very slowly, with a serious face, as doctorly as I could, and then gravely pronounced him “Well.” And…it worked.

* * *

I would like to improve at dealing with angry, challenging patients. Not the ones who come in angry that they are ill, that they had something horrible happen to them, that they had to wait. Those who come in immediately hostile to doctors and to me, often to women in general, and who immediately challenge me on every point, including “Good morning.” They often have very suspicious streaks toward the world in general, or narcissistic ones that mean that no one is a good enough doctor for them, that they aren’t getting the treatment they deserve, no matter what. They also often come from a perspective or worldview that is very violent or power-struggle oriented, in which the way to get something is through a show of threat.

I suck at these patients. One reason is that they are usually men who are physically bigger than me (I’m a teeny thing, even if my presence is larger than life sometimes, ha ha), and it’s always a little scary for me to step alone into an exam room with them. I rarely know these patients beforehand, so I don’t have any gauge of violent potential or what will make them blow.

Furthermore, while I can call security to come stand there, to me that seems like it would just make everything worse. Maybe not, though. Maybe I need to reconsider.

I used to think this was just a situation to deal with, that they were whatever they were for their own reasons, and I just needed to get in and out of there as fast as possible. On some level, I’m probably angry at them for them being able to scare me. I am sure that they see that they intimidate me. Then, they end up pushing me more and more for unnecessary testing, and nothing every satisfies them. A good example would be the father of the girl with no acute problem.

But I’ve noticed that some doctors walk in and manage to defuse the situation, at least partially, very quickly. Lately, I’ve been watching very closely, trying to figure out what they are doing.

I have been dealing with them in the same way that I deal with most patients, explaining everything I am doing and thinking. I think this is where I go wrong. The doctors who manage to deal with them, sometimes even get a “thank you, doctor” from them at the end, don’t do anything like this. They usually walk in very calmly, sit very close to the patient, and are absolutely unruffled by the aggression. Now, to be fair, I’ve seen mostly men who are very gentle by nature do this. And usually they are older than I am, with those few gray hairs that make them look more authoritative, more “like doctors” than I do.

They take a history, explain nothing except what will happen next. Then, at discharge, they say confidently what it is (without admitting to the uncertainty involved in almost any diagnosis), state that the patient will be fine or needs to do x, y or z, and walk out.

I think that what happens is something like this. These patients see everything as a power struggle or hierarchy. This is a primitive kind of thinking, but it is what it is. The doctors who deal with them well, I think, do something like this: they walk in and establish their authority immediately. They use the position of doctor and the socioeconomic gap as leverage; they are not “fellow human beings” in this relationship.

Yet while they do that, they use their calm, gentle demeanor to establish themselves as benevolent authority. When a patient only understands pecking order, he also understands the concept of being in the subordinate position, and can accept that, and is quite happy when the authority is benign and caring. I suspect this is what happens because the “thank you, doctor” they get is often in a very deferential tone. They say things like, “That guy was a great doctor. He knew exactly what he was talking about.”

A position of equality, or maybe of uncertainty as to where they stand, bothers them; they need to know who is in charge. With someone like me, a kid, and a girl, on top of it, all they know how to do is to push and bully. What I see as being respectful and fair and honest is seen to them as an invitation to try to get “on top.” These are the patients who get angry when I offer them treatment options.

My problem with this is as follows: we don’t always know, even most of the time, we don’t know. We can say it is nothing serious with confidence, but God knows we have no explanation for various headaches, stomachaches, joint pain, constipation, etc.

Here is an example. An older man had hernia surgery. The family was very concerned, because a few hours following the surgery, he had one episode of loss of control of urine. After that, he had no problems and the incident did not recur. They were very concerned, which is reasonable enough – after all, there are nerves down there that are definitely in the area operated on. Had he had a stroke? Had he had a seizure?

After that one time, he had no urinary symptoms, no retention, no incontinence. Normal neuro exam. It had been general anesthesia, not anything in the spinal area.

The family kept pressing me for an answer. Now, I don’t think any doctor has any idea why this happened, except that elderly people can lose continence around a medical stress. I was certain that nothing serious had happened. I said, “I don’t know why it happened. It most likely won’t recur, and there is no evidence of any damage.”

They were pretty unhappy with me.

Then a friend of mine came through (at exactly the stage of training I was), and they asked him. He immediately said, with a ridiculous amount of confidence, “It was a reaction to the anesthetic or the muscle relaxant used during the surgery, that caused the muscle to stop working for a little bit.”

Now, what he said was certainly plausible, though it isn’t really a listed complication of anesthesia. Was there any evidence that what he said was actually what happened, other than “it could have been?” No. But the family was overjoyed with this “explanation,” and loved him, while assuming I was a shitty doctor.

Most doctors do this a lot for something minor – come up with some “explanation” that sounds vaguely physiological, something that they could believe themselves. But I always feel dishonest if I do this, if I say, “We know exactly” when we don’t. When doctors discharge someone with non-serious, yet undiagnosable complaints that will probably go away on their own, they usually throw a medical word or two at it: You have “gastritis.” You have “a slipped disc.” Do they actually know the stomach is inflamed, or is the history very suggestive of it? Is there any evidence to suggest that the disc is the cause of the pain?

I have trouble doing that. I feel dishonest. I usually say something like, “You don’t have appendicitis. You don’t have gallstones. You don’t have a perforated ulcer. You don’t have anything dangerous at this moment. Given the symptoms you have and the way they occurred, it is most probably infectious and should go away on its own.” I am always afraid to toss out one of those half-assed diagnoses, because I always think that it is possible that as the natural course of the disease plays out, a different and more clear diagnosis will come through, and I’ll be the idiot who said the wrong thing.

But it seems like people really want that. Ambiguity is, apparently, a tough pill to swallow.

* * *

As for me, I seem to be doing better, as evidenced by the fact that I’m writing about medicine and life, rather than my own personal misery. In fact, I’m not sure I want this blog to take that direction; medicine consumes enough of my life, and this was supposed to be an outlet for other things, for me. My misery blog. I wouldn’t want to gather a readership that is the “medblog” group. This is where I want to be allowed not to be a doctor.

And most misery blogs get boring or abandoned once the writers get well. I mean, I’m happy for them and all, but reading these kinds of blogs, well, we mostly do it to find someone who feels bad too. During my well periods, I usually abandon this blog.

But I’m going ahead with it, at least this time, because it is roughly a continuation of the last post and touches on some psych issues, if not mine.

And knowing me, don’t worry, more misery will be on the heels of this good spell. Just stay tuned.

What is the universe trying to tell me with this?

As far as how I’m doing, it’s close to an exact copy of this post, so I won’t go into it. I had a very nice call night, though, now that I’m feeling slightly better. Actually, it was a horrific call night, in that patients kept coming in nonstop for the whole night. The volume was one of the highest I have ever seen. I did not eat, drink, or take a piss for 16 hours. There was no five minute break to catch my breath, to smoke. When I sat down to write letters, I felt my heart pounding from dehydration, but didn’t even have time for a glass of water.

But once I felt better, I enjoyed the patients again. I found my sense of agape for them again, for all their funny ways. Also, the excessive patient load meant that there was no time for dinner so I didn’t have to spend an hour listening to some docs talk about the usual medical politics and their crap. Everyone was so busy that I was spared interaction with the other docs…and the other two were both decent ones, two young women, who are on the low end of the jerk scale for the internal med folks. One even has a nose ring – I wanted to ask her if anyone ever said anything about it.

Even though it was brutal, I liked the work and felt useful again, and only had brief moments of an overwhelmed feeling.

Here is the funny thing from the universe: I saw about 6 psych patients in a row, all sent for medical clearance. Our emergency room is run by specialists at night – there are no “ER docs.” The on-call physician (resident) for each department covers the ER, and triage directs the patients to the appropriate specialty. When I work there, I am either working as an ER surgeon or internist, doing either the stitches or the heart attacks, but not both.

Sometimes patients come in and are triaged to be seen by more than one specialty. This is a horrible system, an excess of a tertiary care, behemoth university hospital – people never get out of there, and often the nurse who does the triage is not very good. Most of the patients  could be handled by a primary care person, but they aren’t.

An example would be a minor head trauma. Someone gets hit by a baseball, and gets a black eye and a big lump on his forehead, let’s even add that he needs three stitches above their eyebrow. Low impact trauma, no loss of consciousness, no vomiting, no reason to think of a fracture. If this person were to go to his regular family doc, he’d get a quick evaluation of the eye and eye movements, brief neuro eval and explanation of dangerous signs to watch for, a stitch-up, and be sent on his way.

If he goes to our major tertiary care center, the triage nurse, who is often also not an RN, will triage him to ophthalmology, neurosurgery (they clear all head trauma), and plastic surgery. The plastic surgeon is in the theater, so that’s a wait of three hours. The neurosurgeon on call refuses to see patients without a CT, so that’s extra radiation and cost. The eye doc is a typical eye doc and refuses to leave the eye department in another building to come to the ER, so the guy has to get sent over there with medical escort. What could have been a fifteen minute in-and-out turns into an 8 hour ordeal. Don’t even get me started on this subject because I will FLIP OUT.

Here’s the weird “message from the universe” part. After I suddenly started feeling better and being able to work again, on that very same call night, I ended up seeing six patients who were triaged to internal medicine + psychiatry. That’s really rare. Usually I go weeks at a time without seeing a psych patient who comes for both psych and physical illness.

Trying to fix their psych problems would drive me crazy, be so protracted and Sisyphean that I’d lose patience. But seeing them for medical problems made me feel like I was in the right place, like I had a calling. I knew that a lot of doctors wouldn’t treat them as people, would lose patience, would count them off as crazy. I was glad to see them, without judging.

I actually felt like I was good at what I was doing, mixing medicine with the humanity that only recently started to come back. I’m, of course, changing a lot of details, though no case was particularly unusual, all were the kinds of things seen in any ER shift.

For the first time in a long time, I didn’t want to run away from clinical medicine. While I’d never choose to have the kind of suffering I have, I felt that maybe my being crazy had given me a gift; I’m not sure how to describe it without slipping into a cliche that I don’t mean. Not the “gift of empathy” or anything bullshit thing like that. Something less specific, something amorphous. Appreciation for crazy, and the people living with it wiggling around in them, maybe.

The first forty-ish guy was talking incredibly fast with circumstantial thinking who kept returning to telling me about his stress at work. I couldn’t even get out of him why he was in the ER except that when he started his monologue there was some phrase like “funny feeling all day.” I let him go on for maybe 5-10 minutes, waiting for the story to come out. It didn’t.

The ER docs hate me for this, that I don’t interrupt patients (it feels rude to me, but my go-with-the-flow approach often makes me look unauthoritative) because they want always a very quick, single complaint, direct history in two minutes. But if you let them go, most patients get to the point within a minute or two anyway, and I don’t feel rude.

This guy didn’t. He just recapped all the events of his day in a very flight-of-ideas manner about how much pressure he was under. Then, in the middle of a run-on sentence about his soon-t0-be-ex wife and how today he had to fill in for someone else at work and said, in the same racing speech, almost incidentally, “Oh, there it is, the pain again…then I was at work and at the last minute they told me I needed to do something for Paul and I got nervous…” He kept going, apparently undisturbed, but also turned gray and started sweating during the same monologue.

“Wait, stop, we’ll talk about work in a minute, but what pain? Where does it hurt?”

“You know, like today when I was going upstairs at the last minute to fill in for Paul, butterfly feeling here in my chest.” He then did the classic heart attack hand thing.

I immediately went and grabbed the nearest EKG machine (didn’t want to wait for the technician to show up), and hooked him up, while all the while he was talking undisturbed, but also looking just like a guy having a major heart attack. Sure enough – huge anterolateral infarct.

It was a strange thing – easily could have been dismissed. If he had been seen in the first ten minutes, between the pains, with no story other than “butterflies,” he could have been discharged and dropped dead in the street. I could have dismissed him as crazy if I had been feeling less well and less patient myself, if I had been depressed like I had been the week before.

But I didn’t miss it.

I’m not saying, oh look, I’m a great doctor, I listen and help, and those ER docs don’t. I could have missed it as easily as any one of them. If I had seen him in the standard 7 minute visit, it is entirely possible that I would have heard “funny feeling in my chest” in a patient who young, was obviously highly agitated and under a lot of external stressors, without seeing the heart attack. Anyone could have dismissed him under the heading of anxiety.

This particular day, I had started to feel better, to want to help people, felt once again able to care. And this particular same day, there were six patients who, I think, were uniquely helped by me. It seemed well beyond coincidence.

* * *

Another patient I saw had catatonic schizophrenia, first outbreak. I don’t know much about that state, I think it is kind of rare. There was the waxy posturing. Eyes closed, she was unresponsive to speech and much of anything, except by breathing and swallowing. I was called to rule out a medical cause, though the story was classic for schizophrenia.

I was curious. I don’t know what exactly that state is, other than recognition of the clinical definition of it. I don’t know what it is like inside, whether it is a result of a psychotic delusion or hallucination that instructs them to stop moving, or a reaction to overwhelming internal stimuli, or a movement disorder related to dopamine disturbances at the core of the disease process. I still can’t find an answer to the internal experience of it – only phenomenology. If anyone knows what it is like inside or can find a description, let me know, please.

I didn’t know what was going on inside, but I decided to assume that she could hear outside stimuli as well as whatever the internal ones were, it seemed like she changed breathing patterns sometimes in relation to things her family was saying to her. And in my past experience, external stimuli get through the overwhelming internal stimuli. You can communicate, at least partially, with someone in a psychotic episode. My gut feeling was that it was an overwhelming internal delusion that forbid her to move. I thought that if it was a terrifying experience, if something was threatening her not to move, that a physical examination would probably be a pretty horrible experience.

So I tried to explain in the most non-threatening voice possible that I was a doctor, I was going to examine her, it wouldn’t hurt, and if I touched something that hurt, to please give me some kind of sign so I could help her. I have no idea if she heard or not. There was no way to make any connection with her, but I hope that at least it was as gentle and nonthreatening as possible.

* * *

A girl was brought in by her parents the morning after taking an overdose of a benzo. It was far from the first time, though she was young, college-aged. She’s the one I mentioned in the last post. The quick way she slipped into anger and the surrounding entourage meant to me that most probably she had borderline traits/disorder, but she was a person, with a million other qualities besides that.

By the time she got to me, the short acting benzo, of which she hadn’t taken that much anyway, was far out of her system and there was, as they say, nothing to see. The first thing she asked me was if she was going to get an NG tube. Ah, the voice of experience. I didn’t want to do the whole psych evaluation, I didn’t want to be so clinical. I just asked her if anything particular had happened last night, and she said no, just a buildup of being sick of it all, a collective sense of hopelessness and exhaustion of never being better.

I just said, “Yeah, it’s like that sometimes.” I meant it. I liked her.

While examining her, I asked what she thought would happen when she did it. She got some tears in her eyes and said, “I didn’t want to wake up.” But she didn’t mean it. They were those forced tears, trying to show me how miserable she was, one of those bids for sympathy, an inability to be able to name her problem and express it. She was trying to show me how much it hurt in the only way she could.

Instead, I joked with her a little and she laughed. I wanted her to get a good consult, so I told her, “Let me go see who the psychiatrist is today, if it’s someone ok. If not, maybe we’ll just talk.”

She laughed, and said, “Yeah, you wouldn’t believe some of the ones I’ve been to.” I laughed too. “I know what you mean.” God knows I know what she meant.

I left her behind the curtain with her parents. I didn’t know the psych on call, if he was any good or who he was even. I called him to let him know he had a consult. Pretty soon there was yelling from behind the curtains, but I didn’t hear the specifics. I didn’t get involved.

One of the things I like about dealing with people with borderline is that they’re so changeable. By the time they actually get to the emergency room, they’ve usually chilled out. They’re mercurial, like quicksilver. It’s not like dealing with someone who is depressed, with that heavy atmosphere, the hopelessness. With the right attitude, you can almost always share a laugh with them, joke them out of their misery and into some human contact for a minute or two at least. If they’re furious at you, it’s ok, because it will blow over sooner or later and you can go back to being cool.

* * *

I’d like to write about one more case, but I’m pretty busy and have to attend to some things today. Tomorrow I’m back on call, but in the surgical ER instead.

The point of all this was that it was such a strange coincidence. On the exact same day that I returned to function, I got all these psych patients who I really liked, who were a good fit for me as a doctor. Maybe that’s my niche. Not psychiatry – I’m not interested in trying to fix the mental health problems, I mean, as far as my opinion on that, people are what they are, and if they’re crazy, well, that’s just what they are and it’s not my place to pass judgment.

But maybe I should just be their doctor, one who can look past the crazy, or understand it, or even like them better for it. Maybe that’s the right place for me to be.

* * *
I started the new year with a visit to the shrink. It was alright. I am more normal now than I have been for a while. And inexplicably, he said he didn’t like the bupropion on me. I have no fucking idea why. I kept asking, and not getting a real answer. “It has side effects, and we want something that is going to be long-term.” I said I can live with the side effects (eye tic, panic attacks), that I feel normal again, that even the good old drug had lots of side effects.

I never know where the fuck he is coming from.

It’s odd, even though I feel better than I have in a while, all the sudden he’s saying I’m not ok. For once, I was actually present, not through the filter of depression or a hypo/irritable state, and I get a really bad reaction from him. I just don’t get it. I left there with a very unsettled feeling about the whole thing. I meant to address this directly (the phone call, and I guess today is an extension of it). I have no idea if the problem is with me, or with him. But I ran out of time before bringing it up.

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