Tag: patients

Enter a Closing Door

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Enter autumn as you would
a closing door.  Quickly,
cautiously.  Look for something inside
that promises color, but be wary
of its cast–a desolate reflection,
an indelible tint.
~Pamela Steed Hill from “September Pitch”

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The door of summer has closed quickly behind me;
I am back to long days and interrupted evenings,
of worried voices and midnight calls with over-the-phone sobs,
of emergency room referrals and work-them-in schedules.

I want to tell them it’ll be okay, hug away their anguish
despite the encroaching lengthened nights;
that winter coming does not mean
the end of all.
It takes a background of darkness
for the light to shine brightest
Shadows are borne from illumination~
It will be okay, even now, even so.

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Places in the Heart

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Man has places in his heart which do not yet exist,
and into them enters suffering,
in order that they may have existence.
~Leon Bloy

I see these new heart chambers forming every day.
Spaces filling overwhelmed as if water frozen,
with hurt
and loss
and despair.
So I try
to help patients let go of
their suffering,
let it pass, let its ice melt down,
allow it to pass through,
forgiving, forgiven,
their hearts changed
by a grace
flowing warm
from new found gratitude.

Now and Now

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photo by Josh Scholten
photo by Josh Scholten

And so you have a life that you are living only now, now and now and now, gone before you can speak of it, and you must be thankful for living day by day, moment by moment … a life in the breath and pulse and living light of the present…
~Wendell Berry

My days are filled with anxious people, one after another after another.  They sit at the edge of their seat, eyes brimming, fingers gripping the arms of the chair.  Each moment, each breath, each rapid heart beat overwhelmed by fear-filled questions:  will there be another breath?  must there be another breath?   Must this life go on like this in panic of what the next moment will bring?

The only thing more frightening than the unknown is the known that the next moment will be just like the last.  There is a deficit of thankfulness, no recognition of a moment just passed that can never be retrieved and relived.   There is only fear of the next and the next so that the now and now is lost forever.

Their worry and angst is contagious as the flu.
I mask up and wash my hands of it throughout the day.
I wish a vaccination could protect us all from unnamed fears.

I want to say to them and myself:
Stop.  Stop this.  Stop this moment in time.
Stop expecting some one, some thing or some drug must fix this feeling.
Stop being blind and deaf to the gift of each breath.
Just stop.
And simply be.

I want to say:
this moment is ours,
this moment of weeping and sharing
and breath and pulse and light.
Shout for joy in it.
Celebrate it.
Be thankful for tears that can flow over grateful lips.

Stop me before I write,
because of my own anxiety,
yet another prescription
you don’t really need.

Just be–
and be blessed–
in the now and now.

Obscurity in Medicine

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photo by Josh Scholten

Be obscure clearly.
~E. B. White

As a family doctor, I work at clarifying obscurity about the human condition daily, dependent on my patients to communicate the information I need to make a sound diagnosis and treatment recommendation.  To begin with, there is much that is still unknown and difficult to understand about psychology, physiology and anatomy.  Then throw in a disease process or two or three to complicate what appears to be “normal”, and further consider the side effects and complications of various treatments — even evidence-based decision making isn’t equipped to reflect perfectly the best and only solution to a problem.  Sometimes the solution is very muddy, not at all pristine and clear.
Let’s face the lack of facts.  A physician’s clinical work is obscure even on the best of days when everything goes well.  We hope our patients can communicate their concerns as clearly as possible, reflecting accurately what is happening with their health.  In a typical clinic day we see things we’ve never seen before, must expect the unexpected, learn things we never thought we’d need to know, attempt to make the better choice between competing treatment alternatives, unlearn things we thought were gospel truth but have just been disproved by the latest double blind controlled study which may later be reversed by a newer study.   Our footing is quicksand much of the time even though our patients trust we are giving them rock-solid advice based on a foundation of truth learned over years of education and training.   Add in medical decision-making that is driven by cultural, political or financial outcomes rather than what works best for the individual, and our clinical clarity becomes even further obscured.

Over thirty years of doctoring in the midst of the mystery of medicine — learning, unlearning, listening, discerning, explaining, guessing, hoping,  along with a little silent praying — has taught me the humility that any good clinician must have when making decisions with and about patients.  What works well for one patient may not be at all appropriate for another despite what the evidence says or what an insurance company or the government is willing to pay for.  Each person we work with deserves the clarity of a fresh look and perspective, to be “known” and understood for their unique circumstances rather than treated by cook-book algorithm.  The complex reality of health care reform may dictate something quite different.

The future of medicine is dependent on finding clarifying solutions to help unmuddy the health care decisions our patients face. We have entered a time of information technology that is unparalleled in bringing improved communication between clinicians and patients because of more easily shared electronic records.  The pitfall of not knowing what work up was previously done will be a thing of the past.  The risk and cost of redundant procedures can be avoided.  The patient shares responsibility for maintenance of their medical records and assists the diagnostic process by providing online symptom and outcomes documentation.   The benefit of this shared record is not that all the muddiness in medicine is eliminated, but that an enhanced transparent partnership between clinician and patient develops,  reflecting a relationship able to transcend the unknowns.

So we can be obscure clearly.   Lives depend on it.

Spicy Feet

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photo of bee on a lemon blossom by Nate Gibson

“Bees do have a smell, you know, and if they don’t they should, for their feet are dusted with spices from a million flowers.”
― Ray Bradbury, Dandelion Wine

I admire the honey bee’s ability to become pollinator and pollen gatherer simultaneously, facilitating new fruit from the blossom as well as making sweet honey that carries the spicy essence of the flower touched.

As a physician, I wish I might be as transformative in the work I do every day.  I carry with me tens of thousands of patients I’ve seen over thirty years of medical practice.   There is no way I can touch another human being without keeping some small part of them with me–a memory of an open wound or the scar it left behind, a word of sorrow or gratitude, a grimace, a tear or a smile.  Each is a flower visited, some still in bud, some in full bloom, some seed pods ready to burst, some spent and wilting and ready to fall away.  Each carries a spicy vitality, even in their illness and dying, that is unforgettable and still clings to me.  It has been my privilege to be thoroughly dusted by those I’ve loved and cared for.  I want to carry that on to create something wonderful.

Each patient changes me, the doctor, readying me for the next patient by teaching me a gentler approach, a clearer explanation, a slower leave-taking.  Their story becomes part of my story, adding to my skill as a healer, and never to be forgotten.

Physicians do have blessings in the work they do, you know, and if they don’t they should, for they are dusted with stories from a million patients visited.

Nothing could smell as spicy and nothing could taste as sweet.

Hearing Hoofbeats

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It is critical for physicians to share unusual patient diagnoses that present to clinic with routine type symptoms. In a hospital setting, these are cases for discussion and debate at Grand Rounds. In a primary care setting, we do case reviews when we can with informal sharing for the purpose of teaching and learning. The bottom line, whether in a formal academic setting, or an informal setting around the lunch table: clinicians need to always be thinking of the possibility of a zebra hiding in camouflage among the many ponies in the primary care setting.

After twenty two years working as a physician in college health and seeing two or three extraordinary cases every year, suddenly I’ve seen three “once in a career” patients in the last three months.

Several weeks ago I saw an otherwise healthy student with an unusual rash and history of nightsweats for two weeks. The well circumscribed large erythematous lesions matched photos I looked up of erythema marginatum which can occur with rheumatic fever from Group A strep infection. The student had never had a sore throat but did have a positive rapid strep test that day as well as a markedly elevated streptozyme and sed rate, and met other clinical criteria of rheumatic fever. The infectious disease consultants agreed. Thankfully the student was diagnosed and treated early enough that echocardiogram was normal. The rash and sweats disappeared within 48 hours on Penicillin VK. This is believed to be the only case of rheumatic fever in our state this year.

Last week I saw an otherwise healthy student with a history of a pet rat having bitten an index finger a week before. The bite healed without intervention but the student was feeling generally unwell with headache, nausea, fever, chills and muscle and joint aches, as well as a new macular rash of discrete erythematous lesions on palms and soles, extending to the dorsum of the feet. All symptoms appeared classic for rat bite fever, a rare infection by Streptobacillus moniliformis with a 25% mortality rate if left untreated. Blood cultures remain negative but must be kept at least three weeks for this particular bacteria. The patient has finished a week of IV antibiotics while remaining in school and all symptoms have improved. There are apparently very few cases in the U.S. annually but since it is not reportable, the incidence is unclear.

Also last week an otherwise healthy student was hospitalized in septic shock after being seen twice in emergency rooms while home over Thanksgiving break–fever, sore throat, nausea, muscle aches that appeared viral to the evaluating clinicians. The student came back to school still sick, went to the local emergency room when feeling so lightheaded that walking was difficult, ended up in ICU on a ventilator due to incipient respiratory failure. It took several days of touch and go clinical management for the diagnosis to become clear: Lemierre’s Syndrome–septic thromboembolism to the lungs that results from a gram negative infection in the throat and causes deep pharyngeal abscesses, with a jugular vein that becomes infected with septic emboli. The student was initially placed empirically on three antibiotics by the infectious disease specialist so was being appropriately treated even before the diagnosis was obvious, and will likely be on IV antibiotics at home for up to eight weeks due to the persistence of the emboli. Lemierre’s is something that is reported two or three times a year in young adults nationally and carries a significant mortality rate.

These three patients have survived these devastating infections. I’m very humbled by the fact that presentation of routine symptoms in a young adult primary care population should never leave the clinician complacent about what the potential cause might be.

The zebra just might be hiding in the bushes, right in the middle of a herd of horses.