Giving Bad News

Giving bad news never gets easier. And the older I get the more difficult it becomes. I suppose it's because I now have more life experience and when I was a younger doctor I could easily separate patients' lives from my own. Recently, I had to tell a woman that she has metastatic cancer. I had suspected as much but, like her, I was holding out unrealistic hope.

The past week or so I've been having paroxysms of sharp pain in my right temple and in my back, over my ribs on the right. The pain doesn't last long, seconds, but the rib pain, especially, catches my breath.

Normally, I'm prone to ruminating over whatever ache or pain I may be experiencing. Let me clarify, I don't ruminate frequently, but when I do have a pain, my mind immediately conjures the worst case scenario with me dead within weeks to months.

The mind and body have such a powerful connection. I'm not particularly new-agey but things in your subconscious can manifest themselves in many different ways, both bizarre and simple. Over time, doctors develop coping mechanisms to deal with unpleasant and uncomfortable feelings. Humor and repression are two popular and convenient ways to handle them. My husband is on a committee that deals with professionalism and medical students. Many of the committee members are not clinicians, meaning they have no patient contact. To them, some of the things that are spoken during rounds or in clinic would be incredulous. What they don't understand is that clinicians, on the whole, aren't cold and insensitive; we're simply trying to stay sane. In his brilliance, my husband has developed something called "the box of unprofessionalism". It's kind of like a confessional booth in that while you are standing in the box of unprofessionalism (which is far away from patient care areas and behind closed doors) you can say whatever you like without reprimand. It's not that he embraces insensitivity or crassness, rather he understands the importance of decompressing during incredibly stressful situations. (Maybe this is why he wins so many teaching awards).

For several days I've been repressing my grief over my patient's diagnosis. I had to tell someone, speak aloud, the words no one wants to hear. Every year Lee and I, along with one of our colleague's, give a lecture to the medical students about being a doctor and having an illness. We all discuss how your life changes the day you (or a loved one) receive the unwelcome news. All of the sudden you have to alter the landscape of your life. As a doctor, I don't think I can discount or underestimate the significance of giving another person equally life-altering news. What's the correct way to process? There is no course in medical school or residency that tells you how you are supposed to act, feel, behave. And for how long afterwards should you feel like shit? What's that patient thinking right now? Is she scared? Resolved? Indignant? Angry? I'll tell you how I feel, overwhelmingly sad and if I'm really honest with myself, guilty. Why her and not me? Why do I have the burden and responsibility of reminding someone of their own mortality and why is her number up and not mine?

I think that if I could get alone for a bit I'd probably have a good cry and I think I need a good cry. Not just for myself, but for that lady. Maybe the lump in my throat would go away and the pain in my head and the ache in my back.

One last thing, especially since I'm typing this on my phone while my family is on a road trip and my kids are about to mutiny because they want lunch (and maybe that's why I can finally think about this. I'm not helping someone with homework, or finishing a yearbook, or paying a bill. I'm on vacation); it's a story from medical school. When I was a second year student on my general surgery rotation, my friend and I were given the task of sewing closed a young man's chest cavity after he had died. I can't remember the mechanism of his accident, either a gun shot wound or a car accident, but he had been brought into the emergency room as a shock, meaning he was being artificially resuscitated. Well, chest compressions alone weren't reviving him, so the surgeons cracked his chest and performed cardiac massage. After what seemed like an eternity, they called the code realizing nothing was going bring the guy back to life. What had moments before been a shock room full of frenzied activity was now silent, with me, my friend and the dead man. The nurses and surgeons had gone to talk to the family and left us to "close him up" so he would be presentable to his family and so we could "practice our suturing skills." So Carie and I stood there, silently, each carefully sewing up one side of his thorax. Sometimes we still talk about that night an how ill-equipped we were to be given such a responsibility and how, afterwards, no one but us thought it was a big deal. When the surgeon came back in he said, "Good job, but make sure to take the tube out of his mouth because it's upsetting to the family." And that was it.

In the 22 years since I started medical school, they have advanced a lot in terms of sensitivity training and all of that 21st century PC stuff (no such beast as a professionalism committee in the early 90s), but personally, it never gets any easier and I hope it never does.




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House Guests

Text sent to my father this morning, 2 days before our trek to visit him. No offense to any Lithuanians....

Yo daddy....you awake? Wanna make sure you and Jan are still ok w/ us coming out there. You seem a bit hesitant about the number of house guests. Is it stressing you or Jan out too much?

By the way...I hope you don't mind, but we are hosting a band of Lithuanian foreign exchange students and their flock of camels. We feel bad about leaving them behind with the language barrier and all. We figure there is enough space for the camels in the yard and the Lithuanians don't take up too much space...they are compact and you can stack them on top of each other. Maybe one or two can sleep in the bed with you and Jan. They are cuddly creatures. By the way, the camels are gluten free, so would be good to have some grain free camel kibble for them. The good news is you can reuse the dung in your compost. You'll have award winning azaleas next year. If you don't get the grain free stuff, they get gassy and, pardon my language, but that shit smells and then the whole situation can get uncomfortable. On the whole, they've been delightful and I think you'll enjoy the lively, high spirited bunch. And the good news is they are a very loyal people so they are likely to come back next year and they usually bring with them many distant relatives and livestock


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Saturday Morning

It's a beautiful Saturday morning and I'm sitting in my front yard watching 2 of my kids play lacrosse with our neighbors (and hoping to God that no one breaks a window or dents a car) and not helping my oldest kid with his science homework (because it involves physics and I suck at physics and I was giving him the wrong answers).

The best part of today is: WE HAVE NOTHING SCHEDULED!!!! This is a minor miracle. The other best part is I can sit in my front yard in my pajamas and no one cares. Let me clarify; I'm not wearing a neglige (in which case people might turn to stone if they cast a glance upon me and my middle-aged physique) but flannel bottoms and a sweatshirt. And I'm wrapped in a blanket drinking my coffee. This is considered appropriate weekend attire on my street (especially considering we have a batty old lady who routinely walks up and down the street in her inside out pjs and peers into everyone's cars, windows and trash cans).

The kids and neighbor kids have decided that using one of our plastic adirondack chairs as a target would be a good idea. And from an 11 year old boy's perspective it is very ingenious. From the broken chair's perspective, not so much. In case you didn't realize this, children destroy things. Usually it's not intentional but the formula is directly proportional; the higher the concentration of boys the greater likelihood you have for destruction.

Middle kid's best bud moved in across the street. This is a good thing. However, right now they are in a battle over how to calculate points per shot. It's like I'm watching a political debate and tempers are flaring. It's a completely ridiculous and stupid argument and they've already been warned so now they are each in their own penalty boxes on separate sides of the street. Not sure if this is the best way to handle it or if I should just let them work it out themselves but the volume of bickering was starting to disturb my peaceful morning. Now they've crossed to the middle of the street, shook hands and negotiated rules.

This morning our dog (# 2 of 3) relieved himself in my bathroom and closet. I thought one of the boys had failed to flush...Puffy (i realize that some might consider this an effeminate name, but his given name is Puff Doggy and he is quite secure in his masculinity-even though he's a eunuch) took a piss on the corner of a stool and the pee had spread through all the grout lines like little rivers and streams. As if this wasn't enough, he, or possibly dog #3 (the geriatric beast, age unknown, who is vision, hearing and cognitively impaired) took a poop in my closet.









I haven't perfected my turd identification skills so with the absence of DNA testing, I couldn't determine who dropped the 2 desiccated turds. So, they were both cast outside. I suspect it was all the little, middle dog as he is too scared to walk down the hallway leading from our room to the back door. We put one of those buzzer discs under a chair near the path so he wouldn't get on the chair but he's too dumb to realize that his collar wasn't even on his neck. That and I watched the old dog take a poop outside this morning so I could better characterize each dogs' poop. Old dog's poop is more of an orange hue, a bit bigger in diameter and not so dry.

The funny thing about the dog collar alarm system is that whenever one of the batteries goes low in a smoke detector and starts to beep, the dogs freak out. It's psychological torture because they think it's the big dog alarm in the sky. Even though their collars don't buzz, the noise must be the exact same pitch as the dog alarm noise. In a sick an sadistic way, it's kind of funny....

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Waiting

I'm sitting in the UT Aquatic Center at another water polo extravaganza. At the end of the day we'll know if our oldest kid has been selected to continue to the regional games. This is very nerve-wracking stuff. I'm trying to be all zen about it, but mama bear doesn't like it when her bear cub is being evaluated. Regardless of the outcome we are proud of him, but I really, really hope he makes it!

Athletically, I am not a competitive person, so this concept of trying out for a team is not intuitive. Maybe because I was the fat, slow kid who was always picked last I shied away from team sports and competitions. I remember the sting of "not being good enough" and I don't want that for my kid. Of course I'm transferring all my own crap onto him and I'm pretty sure he doesn't wrestle the same demons I did.

I met a nice mom and we talked for a long time this morning. I think that at these kinds of things parents are either too nervous to talk or they don't want to get friendly with the competition. Her son is one of the young ones, like mine, trying out for this thing. We were like minded in many of our parenting theories. Also, talking made me less anxious.





I know I'm gonna chicken out and make Lee be the one to be here when they announce which 14 out of 18 kids get to continue. Every time they blow a whistle or point or say something to my kid or if he's waiting on the side of the pool, I'm a freaking nervous wreck, reading all sorts of things in to it. And there is this little Asian female coach who is a drill sergeant. I don't know about my kid, but she scares the poop outta me.

Okay, gotta watch now. He's in. Keep your fingers crossed...more for me than for him!

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The Good Intern

Yesterday was a good ER day. The patients weren't all that interesting and most of them didn't need to be seen in an emergency room. The residents, student and I saw a lot of patients in the 12 hours we were there and that is always good from a revenue/RVU generating point of view. It was a good ER day because of the people with whom I worked. Working with learners is a tricky business, especially in the ER when you have 12 hours out of a 3-6 year training period to teach something and/or make an impact while simultaneously trying to keep patients alive and keep up with all the electronic documentation. When evaluating these kids, the students and the residents, unless they have committed some egregious errors, they get the equivalent of an A+ from me even if they've really only performed at a B + level, mostly because it's hard work and just showing up and doing your job gets you a B and if you have some enthusiasm and a good attitude, then you get pushed over into the A to A+ column. Very rarely, I have a C student or resident and recently I had my first ever F resident (and I'm still reeling from that one and have yet to formally document her poor performance). Yesterday I had some genuine A+++ individuals.

One kid, in particular, really had an impact on me yesterday. At the onset of the day I thought I might be working with a couple of duds. They were both kind of quiet and one was a urology intern and the other a family medicine intern so automatically they were suspect for laziness (urology) or dumbness (family medicine). I fully admit that I'm an internal medicine snob. As the day progressed they proved me and my prejudices wrong. The family medicine resident was smart and hard-working and had the air of internal medicine elitism, which I appreciated. But, it was the urology intern that has kept me up most of the night thinking. It's his story to tell and I don't have his consent to disclose it, but he was remarkable and it was not because he was really, really knowledgeable or really, really accomplished. He was remarkable in his ordinariness, decency and humility. This kid seems to have had humble beginnings and then a series of adverse life circumstances and despite this he has extracted all the character developing aspects of the situations and moved on without anger or bitterness.

Surgical interns have a tough job. Despite new duty hour restrictions that are supposed to put limits on the number of hours an intern or resident can stay in the hospital, the supervising surgeons and the surgical programs often ignore these rules. The interns, who are powerless, are subject to the whims of whomever they may be assigned to for the month. This intern had been assigned to an esteemed surgeon but one also notorious for abusive behavior towards his interns and residents. He shared a few stories of his month with the supervising surgeon and I wanted to cry and hug him and he wasn't trying to garner sympathy. After about his third day on the service with this supervising surgeon, he realized he had to just take his knocks and move on.

What I want to do is find this kid's mother and tell her, "job well done. Despite all the shit you and your family have experienced, this is your real treasure standing right before you. If I could fast forward 10-15 years from now and see that my boys had the character, humility and humor of your son, then I'd know it has all been worth it."

I don't know if I'll ever work with this kid again and I certainly hope that 6 years of a surgical residency doesn't alter his character. I don't think it will because I think he has a rare trait called resiliency. I'm not sure he learned anything from me. Maybe I demonstrated to him that not all supervising physicians have to be assholes to prove they are in charge and it is possible to treat your residents decently and humanely (both residents were amazed that I let them leave before check out. I saw no point in them staying there. They had finished their work and I had to stick around anyway and they are the ones working the 60+ hours a week for minimal pay). I certainly learned volumes from him.

Mom 2

Lately, probably because of all the heap, I've been introspective. This self-indulgent pastime is a contact sport. As you may recall, in my texts with my mom, I stated that I'm always trying to prove my worthiness and I know this is rooted in deep-seeded insecurity. The human condition is such an F'ed up thing. Why, at the age of 44, am I still rearranging the puzzle pieces of my life?

So this is it. Illegitimate. If you look up the Merriam-Webster definition in the online student dictionary it says; 1: born of a father and mother who are not married and 2: illegal. The regular dictionary gives you this definition:

il·le·git·i·mate, adjective \-ˈji-tə-mət\

1: not recognized as lawful offspring; specifically : born of parents not married to each other

2: not rightly deduced or inferred : illogical

3: departing from the regular : erratic

4 a : not sanctioned by law : illegal b : not authorized by good usage c of a taxon : published but not in accordance with the rules of the relevant international code

with following synonyms: baseborn, bastard, misbegotten, natural, spurious, supposititious, unfathered


What if you are 19 years old and it is the late 1960s? Do this word and its synonyms have a negative or positive connotation? If suddenly you find your situation described as "not legitimate" by your parents, aunts, uncles, grandparents and community how do you feel about yourself? What if the setting is a deeply Catholic and traditionally Mexican small town? What kind of vibes do you unwittingly pass off to your adorable little bundle? Especially if everyone is playing hot potato with you and your tiny little baby? At 19-20 years of age, you are probably conflicted by all the negative energy that is swirling around your piece of the universe. You love your tiny baby and think she's awesome, but people keep sending you mixed messages. "Your baby is adorable, but you are a f-up. And we need to send you away and pretend this never happened." Even if they aren't saying those exact words, this is all you hear. Everything gets filtered through the lens of condemnation. Kind of hard to recover any shred of self-esteem from this situation and to move forward in a positive, constructive manner. Fast forward 44 years and look back at those texts from yesterday. That 19 year old is the same kick-ass lady who is sending me those positive affirmations. More to come...sorry to put you all through this...this online, literary version of dissecting a garbage disposal, but I warned anyone who might read, this is not for you...it's for me (and maybe my kids someday. If they care)

Mom

Are you ever tired? Bone tired? Not just today or even this week, but deep down, every fiber of your being tired?

I had a text message exchange with my mom today that was simply lovely. I forget how fortunate I am to have her in my life.






















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