lessons learned

internship is sure to be full of learning. we'll learn how to appropriately manage a person coming in with diabetic ketoacidosis and how to change the ventilator settings in a patient in the ICU. in addition, interns learn how to maneuver a new medical system, full of its individual nuances. these are largely the lessons we are expected to master by the time we finish the first year. however, i'm unsure whether there is any expectation and certainly no standardized curriculum for the lessons that come from caring for flawed people in a crazy world. but these are the lessons that shape physicians for better or worse; these are the lessons that give character and preserve our fragile humanity in a more and more technical world.

i learned a few weeks ago that a patient i cared for in an urgent care clinic died suddenly a couple of days after i prescribed her narcotic pain medications. she was a young, depressed women who had recently been thrown to the ground by her abusive boyfriend, causing her to have significant back pain. she was found unresponsive in her home, taken to the ER by ambulance, and pronounced dead on arrival. in cases like these, overdose is highly suspected as otherwise healthy young people have little other reason for sudden death. her body was sent to the medical examiners for autopsy, and the cause of death at this time remains unknown.

whether she died of a sudden arrhythmia or indeed overdosed, this is a tragedy that i feel somewhat culpable about. no, i did not directly administer 40 tablets of narcotic pain medication to her, but i prescribed them to her as is commonly done and as my direct superiors signed off on. as young physicians, it is common to fear that you are going to kill one of your patients by either direct negligence or incorrect direct action, but i'm not sure we think much about the indirect ways we participate in the demise of those we care for by the small actions we take. it would be paralyzing to heavily measure each medication given but it only takes one experience such as mine to drive one to calling the seemingly innocuous acts of our profession to account. i have surely recovered from any since of overwhelming guilt, but i know hesitate momentarily and consider the consequences of supposedly safe and common decisions.

An everyday hero

For the last 3 months, I have worked 3 half days per week in the tuberculosis clinic at the Tarrant County Public Health Department. This endeavor is in hopes of fulfilling a required Public Health Practical Experience for my Master's in Public Health. My major duty is to see patients with the clinic physician, Dr. Weis. Additionally, I attend location-based screening efforts at local homeless shelters, occasionally administer "directly observed therapy" to patient's homes/work places/wherever with one of the outreach workers, work on preliminary research for an observational study investigating current trends in HIV mortality, and spend some time in the refugee clinic. Overall, this has been a wonderful and rewarding experience. The people that serve the public's health are dedicated, hard working, underpaid, and for the most part unrecognized. It has been a lesson in what it means to be a servant to the least among us and thus, all of us.

Because I am ultimately working to become the best doctor for the underserved that I can be, the most important part of my experience has been soaking in the small things that make Dr. Weis the best physician I have ever come in contact with. He is kind and jovial with everyone. He takes all the time that is necessary to make sure the patient understands the plan. He explains and shows every patient's chest x-ray, pointing out the anatomy and any lesions that may exist. These may not seem like extraordinary things, but be sure to remember that most of his patients are homeless or immigrants, ripe with unpleasant smells, addiction, illiteracy, and/or cultural differences that many doctors choose to bull-doze through rather than work within.

Dr. Weis is different from every doctor that I've encountered: He loves his job and can't imagine doing anything else. He cares deeply about a population that in my experience are quickly brushed over or excluded from care (not taking uninsured or medicaid patients) by many in the profession. He has never talked condemningly about a patient's vice, rather he tries to understand their hinderances for good health.

Last week, Dr. Weis performed his most impressive feat. A nurse who does the intitial processing of the patients comes into Dr. Weis's office and informs him that a well-known patient has just arrived. This patient is a Mexican immigrant who had been treated for TB many years ago, and recently became unemployed and is now living on the streets. He has lost a lot of weight and isn't looking very good. The nurse informs Dr. Weis that he doesn't have any money and hasn't eaten in two days.
Without any hesitation, Dr. Weis reaches to his wallet and pulls out $40, hands it to the nurse, and says, "tell him it's from you."
She is surprised and hesitant.
Dr. Weis elaborates, "Tell him it's from you or the health department or someone other than me. He's a friend and I don't want him to feel like he's indebted to me."

I hope I can achieve the patience and generosity of this amazing physician.

mute

I sat in front of this computer for 45 minutes and typed nothing until now. I have not been thinking clearly lately and feel very vapid. I wish I had the words to talk about the myriad of things that have consumed my days in the last few weeks, but I have no words. The mind is cluttered and the soul is restless.
I don't know how to talk about the difficulty of balancing two graduate programs, working 40 hours a week, and being mentally, physically and emotionally available to the amazing individuals in my life. I don't know how to talk about the tragic loss of a friend who personified all that is good in this world. I don't know how to talk about all the controversy surrounding the possible changes at TCOM. I can't express how intimidated I am of the challenges of next semester. I don't know how to explain that lately I feel as if I am surviving more than living.
I need a sabbatical, a time of rest and reliance on God's provision. Not only the provision of the basic survival needs, but provision of mercy and healing love. This time of year, more than any other, is one of great hope, and I hope for restoration.

signs and wonders

while studing intently for our end-of-rotation exam this week, barrett returns from a short break and we have the following short conversation, whose subject i found amusing enough to share:

b: have you been to the bathroom lately?

a: what?

b: the bathroom. on the first floor.

a: ya, sure.

b: is there a sharps container on the wall?

a: what?

b: a sharps container, like for needles.

a: what's a sharps container doing in the library bathroom?

b: i don't know. maybe the powers at be are making it a safer place to shoot up?

a: maybe the new students are so advanced that they're operating in the cubicles?

b: hmmmm.

silence and some studying:

a: have you been to the gym bathroom lately?

b: not really.

a: well the women's locker room has signs up that say "please don't leave your 'personal items' on the bench." i'm confused by what quote-personal-items-end-quote means. is it anything that belongs to me personally or just dirty socks and undies?

b: i have no idea. maybe they mean your used needles. you wait, a sharps box will appear soon.

a: maybe.

the end.

Justice is what love looks like in public. - Cornel West

a snail's life

I get a 'word-a-day' email. Today's word was "argillaceous" meaning "made of, resembling, or relating to clay: clayey." Sometimes the word is interesting or useful, but the thing I love the most about this email is that there is also a "thought for the day." These thoughts are rarely related to the word of the day, but are generally more meaningful to me. A few days ago, the following was the "thought for the day:"

How can a society that exists on instant mashed potatoes, packaged cake mixes, frozen dinners, and instant cameras teach patience to its young? -Paul Sweeney

It's an interesting question. I am one of the young people about whom Mr. Sweeney ponders.

Though my family rarely ate frozen dinners or mashed potatoes, instant or otherwise, we ate at restaurants on a regular basis in order to avoid the trouble of cooking after a long day at work or because we had to rush off to some other obligation so quickly that the prep time required for a full meal would not accommodate our plans. We are not an impatient people (both my parents work with special needs populations), but we are instead a busy people.

Products or services that expedite a process, such as the packaged cake mixes, dining out, computers, commercial airlines, dishwashers, etc., rarely are utilized because the outcomes of the process are improved, rather because the quickening of the process allows for more and more processes to be added to one's day. It's not that we're necessarily impatient, rather that we have created an endlessly demanding lifestyle for ourselves. I firmly believe that lifestyle is chosen, not demanded. There are countless people who make it joyfully through each day without the hustle and bustle (many of the ones I know are economically poor. interesting.); however, most of us are addicted to the initial rush and ultimate numbness that results from frenzy. When I have a particularly full day, I don't have the time to consider the implications of any single component. I just keep going and going and going. It is the unfull and unscheduled day that I feel the emptiness of my life of busy pursuits. It is these days that I feel the regret of rushing through a patient's appointment, not listening to their sorrows, because three other patients were waiting. It is the slow day, that I feel restless and paranoid, like I've missed something, instead of blessed to have a few moments of peace. Perhaps a better question for Mr. Sweeney is "How can a society that exists on instant mashed potatoes, packaged cake mixes, frozen dinners, and instant cameras teach contentment to its young?"

I've found that it is very important for me to intentionally slow myself down, not to learn patience but to learn worth and tranquility. Without deceleration, I have no time to reflect upon what it is I do each day, and then I am but a robot performing my intended function. Time and disciplined relection are necessary for me to be human, to contemplate and feel intensely, and to judge how I should live.

"Old Age-itis"

I have a 96 year old patient who comes to see me every 2-4 weeks for manual therapy. She may be the feistiest patient I've ever cared for. Every time I inquire about why she came in this week, she says, "I have old-age-itis." She never give much information as to how this specifically manifests, so I have to investigate by palpation and further questioning. I'm not sure how much good I do for her, but she keeps coming back, and every time, I learn more and more about her life.

She's ruthlessly independent and very proud of it, as she and her husband (also 96) still live alone. Neither of them drive, so every Tuesday their baby girl (age 70) takes them to doctor's appointments, the barber, and out for a nice lunch. She refuses to let me help her move from the chair to the treatment table. She once told me that old people are like five year old's, they want to try it for themselves because no one believes they're capable.

She is as sharp as a tack, recalling the difficulties of the Depression and quickly criticizing the current state of the educational system. She proudly states that as this country goes down the tubes, she'll know how to live without electricity or running water because much of her life was spent under these circumstances. She's appalled that young cashiers at the supermarket can't do simple math and require the assistance of the register to determine the change she is due. And, having the wisdom that comes with age, she disciplines herself to not go down certain roads of conversation (politics in particular) as it will be fruitless and only work -up herself and everyone else in the room.

Obviously, this lady has made an impression on me. Most impressive is that I want her to teach my other patients what it is to take care of yourself despite the obstacles.

So many of the people I treat are chronic pain patients who have allowed their illness to define them. Instead of acting like a five year old, they submit to the low expectations of most medical professionals they interact with and refuse to take me up on ideas concerning critical components of self care, such as good nutrition, sleep, and especially, staying physically active. Like 96 year old patient using a walker, we all need some help in becoming healthier, be it a therapist or a workout buddy. Asking for help or taking the advise of a professional does not have to be a marker of personal deficiency. Rather, aquiring assistance helps us to recognize that refusal to pursue what is needed is the major barrier for improvement.

Additionally, many of chronic pain patients have related psychiatric issues, including depression or histories of abuse. Many are fully aware of activity, both physical and mental that compromise their state of mind, yet they have been unable to become the master of themselves. They are held captive to unhealthy patterns that are paralysing. I am fully aware that there are immovable external stressors such as poverty, lack of an educational foundation, physical disability, etc. However, we each are endowed with the free will to choose how we percieve and manuver within the external pressures of life. At 96, my patient doesn't see her near blindness and chronic illnesses as unconquerable obstacles of fully living each day, rather they are just part of the context that helps her to see the world for what it it: difficult, but not unbearable. cruel, but not without goodness. finite, but not without hope.