Crime and Punishment

Summertime visits to our cousin Joe’s farm were always greatly anticipated.  We would be allowed several days of freedom exploring the fields and barns, playing hide and seek, reading comic books and Mad Magazines that we never had at our own house.

In addition, we got to play with Joe’s cap guns.  These obnoxious little pistols had the ability to make a popping noise from the roll of “caps” inserted inside.  These seemed more authentic than any of the pretend guns at home.

But I was a girl and got tired of the cowboy or war shooting games quickly.  There is only so much popping you can do and it just isn’t that fun any more.  I was also bored with my brother and cousin playing with the guns endlessly so one day I simply put an end to it by pocketing the last roll of caps in my jacket, thinking I’d slip them back into Joe’s bedroom the next day before we left for home.

It wasn’t until we were home several days later that I was reminded in the middle of breakfast about the roll of caps when my mother came out of the laundry room dangling the coil of dots up for me to see.

“What are these doing in your jacket pocket?”  she asked.  I swallowed my cheerios down hard.

“Guess they belong to Joe.”   I said, not meeting her gaze.

“He gave them to you?”

“Um, not exactly.”

“You took them?”

“Guess so.”

“Does he know you have them?”

“Not exactly.”  I started to cry.  I didn’t even want the stupid things, didn’t even like them.  But I took them.  In fact, I stole them.

She put the roll on the kitchen table in front of me, set a big envelope and a piece of paper and a pencil down in front of me and told me to write an apology to my cousin Joe, as well as my aunt and uncle.  The note would be wrapped around the roll of caps and mailed to them that day.

I was mortified at being caught with ill-gotten gains.  How could I confess this thing I did?  How would I ever make it right with my cousin?  How would he ever trust me again,  and how would my aunt and uncle ever allow me to come visit again?

I wrote slowly, every printed word oozing the guilt I felt.

“Joe, I’m sorry that I took your roll of caps without asking you.  I put them in my pocket where they didn’t belong and forgot about them but that was wrong.  I have never taken anything that wasn’t mine before and I never will again.  I’m very very sorry.”

My mother read it, nodded, sealed up the envelope with the roll of caps inside, put on stamps and we walked out to the mailbox together to mail it.  My stomach hurt and I didn’t think I’d feel okay ever again.

Three days later, my aunt wrote me back:

“Thank you for returning Joe’s caps.  Sometimes we learn hard lessons about doing the right thing and Joe accepts your apology and has learned from your example.  He’s relieved he didn’t lose them as he has to earn the money to pay for them with his allowance.  We’re looking forward to your next visit!  Much love to you.”

Instantly I felt much better.  I’ve never forgotten the sweetness of forgiveness.

Taking a Share of the Blame

This week brought news of yet another high profile death from an uncertain cause in a star with addiction history.   Media accounts included reference to the “27 club” –a lengthy list of famous artists who have perished by their own hand, often unintentionally, at the age of twenty seven.

The reality is that too many fatal overdoses responsible for the deaths of the famous and not-so-famous are from medications that were dispensed by a pharmacist in response to a physician’s legal prescription.  The Who’s Who list of “dead in their prime” celebrities in the headlines is long, many because prescription medications were determined to be the cause of death.   In our county, the medical examiner will routinely notify the physician whose prescribed medication is found at the scene of a drug related death.  It can be a sobering call to receive–as it should be.  It should cause the physician to think twice before they sign their next controlled substance prescription.

It is time for those of us who vowed to “first do no harm”  to share in the responsibility for these deaths.  Without our implicit cooperation –our prescription pads, our signatures and our willingness to please patients, especially the rich and famous, by offering up a hand full of pills for every expressed concern and complaint, there would not be so many empty pill bottles sitting next to corpses, and not so many corpses.  We prescribers, including those professionals with prescriptive authority other than physicians,  need to be accountable for the clinical decisions that place combinations of potentially lethal medications in their patients’ hands and mouths.

In the twenty years I have managed medical detox for addicted patients, I have learned how frequently physicians overprescribe for complaints of anxiety, stress, sadness, insomnia as well as the everyday pain of living in the modern world.   Too many pills per prescription, too many unquestioned refills, too many times written without regard to what another physician may have prescribed a week before, too oblivious to what recreational self medication/beverage may be routinely consumed.  Addicts know well who the easy touches are in the physician community, know exactly what they need to say and do to get the drugs they seek.  Addicts also know to rotate emergency room and pharmacy visits and how to  “borrow” from a family member’s medication supply, as well as where to buy “on the street” when all else fails.

As a prescriber, I’ve learned there are ways to responsibly prescribe chronic opiates and benzodiazepines under a patient/prescriber medication contract.  I prescribe small amounts of certain medications that I know can be a problem and never automatically allow refills.   There are never “after hours” or weekend refills.  When I am concerned about potential abuse, I say “no more”  and mean it, when it is clear the medication is no longer justified for the symptoms.  If a taper is necessary, it is done on a daily dispensing basis through a pharmacy.   I insist on random urine drug tests if I’m not sure if the patient may be self-medicating or possibly diverting the drugs I prescribe.   I check the community pharmacy database if I’m not certain I’m the only prescriber for the patient and I check the hospital medical record system for recent drug-seeking emergency room visits.  With the help of modern collaborative electronic medical record systems,  shared information about a patient’s prescriptions can prevent the tragedy of sharing the blame for a patient’s unnecessary overdose.

No prescriber wants to get the call that the medications they prescribed in good faith, in a spirit of healing and compassion, caused an overdose death.   We can do better, and before the next celebrity’s name hits the headlines, we must do better.

What’s Beneath the “Chief Complaint”

Any primary care clinic has a schedule that lists the appointments of the day in incremental time slots.   There is a column for the name of the patient, the patient’s age, and always there is a place for the reason for the visit–the “chief complaint” according to medical parlance.

A quick review of the “chief complaints” for the day gives the physician a sense of how clinic will flow.   There are the seemingly “quick” concerns, like a blood pressure check, sore throat or ankle sprain, and then there are those that will predictably take longer such as fatigue, trouble sleeping, back pain, or headache.

All health care providers are aware that the chief complaint may not be what the patient really wants to talk about.   Finding out the real concern can be part of the detective work the physician must do.  Sometimes it doesn’t actually reveal itself until the physician’s hand is on the door knob, ready to say goodbye and move on to the next patient.

So I can’t depend on a seemingly routine and straight forward chief complaint to be what it appears on the daily schedule.   When I knock on the exam room door, I need to expect the unexpected.  Otherwise,  I’ll have failed my patient and not done what I’m trained to do–look for what is “beneath” the chief complaint.


“itching” – a patient who reports 2-3 months of daily itching, worse at night, with no other symptoms and no apparent rash.  Treatment for scabies showed no benefit, there has been no significant relief from antihistamines or topical corticosteroids.   Examination is unremarkable with no skin findings other than the excoriations from scratching.  Lab work reveals mildly elevated liver function tests.  Additional labs reveal no acute or chronic infectious hepatitis but further work up confirms primary sclerosing cholangitis.

“back pain” in a patient who had been seen with similar low back pain six months previously, but it has been intermittent up until a week prior to this visit when the patient’s legs feel heavy when going up stairs.  Exam reveals an abnormally “stiff” gait but no leg swelling or neurologic abnormality.  Sed rate is elevated and subsequent MRI scan shows bilateral iliac thrombosis due to a congenitally absent inferior vena cava.

“memory lapses” in a patient who notes two weeks of feeling that it was a struggle to remember something that had happened only a few moments before.  Significant recent stress with fatigue but mental status exam and physical exam appears entirely normal.  Screening lab work reveals a significantly elevated calcium, with subsequent testing showing hyperparathyroidism.  Surgery to remove the offending parathyroid gland reveals incidental papillary thyroid cancer as well.

“constipation” in a patient who has noticed bloating in her lower abdomen for several weeks.  She has had normal cycles on birth control pills, has a negative pregnancy test, and a rock hard 18 week size mass in the pelvis.  Subsequent surgery reveals a rare non-metastasized ovarian malignancy requiring aggressive chemotherapy.

“fatigue” in a patient who is puzzled about having slept for almost 20 hours straight.   General disheveled malnourished appearance and smell suggests issues with being able to do basic self care and an examination reveals needle tracks on both arms.  Admits to daily heroin use but doesn’t think it is connected to the excessive sleep need since drug use has not changed over several years.

“fever” with headache, myalgias, and nausea for two days in a patient whose rapid strep and influenza screen is negative, lab showing normal white count with a left shift.  Blood cultures eventually grow strep viridans from subacute bacterial endocarditis on a previously undiagnosed bicuspid aortic valve, presumably from a dental cleaning a few weeks before.

“rib pain” in the left lower anterolateral chest wall of a patient with a week of dry cough, congestion, and low grade fevers.  Vital signs and pulse oximeter readings are normal, as well as a plain chest xray, a urinalysis shows some red blood cells. Scan of the abdomen rules out kidney stone but suggests a subtle infiltrate in the left lower lobe.  D-dimer is mildly elevated and scan of the chest shows multiple infarcts most likely related to use of combination oral contraceptives.

Any of these routine “chief complaints” could have led me to conclude an every day diagnosis, forming a treatment plan based on standardized clinical guidelines with prediction of an uncomplicated recovery.   But complacency in a primary care setting would be disastrous.

My job is to peel down through the layers and find what lies beneath the symptom that was the patient’s reason for seeking help.   It is that every day mystery that keeps me coming back, day after day, wanting to know what will happen next when I open the exam room door.

High Noon in the Garden Patch

Vegetable gardening is not for the faint of heart.  In the few short weeks of the growing season, there is all manner of botanical birth, growth, reproduction, withering and death in such ultra-compressed fashion, it can leave even the veteran gardener gasping for air.  I consider myself somewhat bold and fearless in my every day roles, as any good physician (or mother) must be, but when it comes to the facts of life as played out in the garden,  I turn all mushy.

This week there was no question what needed to be accomplished.  The sun was shining for the first time in months,  the seeds planted a few weeks ago were finally beginning to show themselves above ground, but they were literally drowning in a sea of weeds.   The joy of germination was turning into the heartbreak of overabundant indiscriminate growth.  It was time for action.

I awoke early, emotionally preparing myself.  I pulled on my jeans and hooded sweatshirt, stepped into rubber boots,  armed my pockets with trowel and garden hook, and adopted a confident stance as I stared at the expanse of green sprouts before me.

“Gonna kill me some weeds,”  I muttered menacingly from under my straw hat, looking like Wyatt Earp at high noon, rolling up my sleeves, and hitching up my pants like a sharp shooter.

I first went to the defense of the carrot row.  Tiny carrot seedlings are some of the most vulnerable in the garden.  They start as two little grass-like shoots, very weed-like in their beginnings.  In a few days, the next shoot is the identity give-away: a feathery leaf looking very much like carrot green tops.  True effective weeding really can’t start until the carrots can be distinguished from weeds, even the look alike frilly weeds that pretend they are carrots so they will be left alone.  Very clever camouflage, but not to my sharp eye.

The real carrots are tender little plants, barely clutching the ground with one little root string as compared to the deep hold that weeds have in the soil.  This work requires down on your hands and knees finger weeding, the dirt-under-the-nails sort-through-each-little-green-shoot-to-find-the-right-one-to-pull technique.  Even so, despite my best intentions, the “real” plants still get pulled accidentally:  my father called that “thinning”, another cruel and painful aspect of gardening when perfectly good plants are pulled out to make more space for the near neighbors.  It still seems all too arbitrary and somewhat capricious.

All this weed-o-cide makes me think about a book I read in the early seventies, “The Secret Life of Plants” by Tompkins and Bird which gave me a new understanding of the challenges of being a plant.  I almost can hear the high pitched little shrieks some scientists have recorded as plants are plucked, cut or mowed down.   Then there is the very real question of what is a weed and how it has become victim to our human prejudice about what is worthwhile to grow and what is not.  Maybe since the dawn of times we humans have watched the slugs, the squirrels, the birds, the deer and the rabbits decide what is tastier, and frankly my dear,  it isn’t the weeds.

But who am I to say that a beet plant is more worthy to exist than quack grass?   What animosity and enormous resource is expended to rid the world of the lovely dandelion’s perfect sphere of seeds about to blow with the wind, or the waxy buttercup meant to tickle a child’s chin into a yellow reflection.

But I’m only the gardener with a job to do.  It’s dirty work, but someone has to do it.

By the end of the morning as the sun beats down directly overhead, neat little rows of honest to goodness domesticated plants become obvious and the garden pathways are littered with weed carcasses as well as a few thinned radishes, beets and carrots.   High noon indeed.  I gaze at my spent weapons–dirty hands and fingertips that are barely recognizable–and sigh deeply.   Until the next skirmish to keep the weedy invaders from infiltrating, I can rest easier knowing my little plants have less chance of being overwhelmed by the encroaching wilderness of weeds and varmints.

So I lay down my arms, clean the dirt from under my fingernails, and sit down to listen to the symphony sounds of plants happily growing…

Like the Touch of a Butterfly

photo by Josh Scholten

July 4 is not only the birthday of our independence as the United States of America.  It is the day we declared to the world:

“We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.”

No one had ever said it out loud before.  Historically there had been many a treatise written and wars won and lost about the right to live, and the right to freedom, but the right to pursue happiness?  Unprecedented– and so typically American.

Declaring it is one thing.  Making it so is quite another matter.  Happiness tends to elude our pursuit.

As the famous American author Nathaniel Hawthorne, born on July 4, wrote:

“Happiness is like a butterfly which, when pursued, is always beyond our grasp, but, if you will sit down quietly, may alight upon you.”

Americans pay a steep price in our noisy and pushy pursuit of happiness.  Perhaps it is the larger mortgage for a bigger house, a wider flat screen TV, the perfect antidepressant medication or the  best recreational substance money can buy, or the tank of gas that will carry us just a little farther down the road in our big trucks, RVs and SUVs.   We try to buy our way to happiness with our charge cards maxed out and find ourselves in a deeper debt pit, putting our life and liberty in serious jeopardy.  Even the government itself, home of the brave and the free,  has never been so deep in deficit spending.

Happiness is not purchased with plastic, but is bought through individual personal sacrifice, making sure others have what they need before we ourselves rest easy.  It is the selfish pursuit of selflessness.  And that is exactly why it is so elusive because inalienable rights don’t come naturally–they must be fought for and then preserved daily.

Much blood has been shed by Americans to guarantee Life and Liberty for others, including citizens of other countries.  If the price paid through the sacrifice of hundreds of thousands of lives has resulted in more happiness, why do we still seem so unsatisfied and miserable?

Perhaps we have it backward, as Hawthorne suggests.  We can’t pursue happiness;  it will find us when we least expect it.

Happiness certainly won’t be found in the fireworks that will be blown up today, or the food consumed, or the free flowing alcohol.    It will be in the quiet moment of realization that we are truly blessed by this incredible place to live and raise our children, and that we need to work harder than ever to make it even better.   We will not be free until we stop allowing our appetites to dictate how we live our lives, but realize true freedom comes when we do what ought to be done to preserve that freedom for future generations.

At that moment, in a silent prayer of thanks to the Creator addressed in our Declaration of Independence, can we know the Happiness that pursues us when we live in a forward thinking spirit of gratitude and sacrifice.

Happiness touches us, like a butterfly, in a moment of grace.

And only then, can we make it so.