To be a Hero

I tell students and young providers that one of the greatest things about being in Family Medicine is that one gets to be a ‘hero’ on a daily basis.
I don’t mean ‘hero’ like: running into a burning building and rescuing a kitten-hero, but more like: significantly improving peoples daily lives-hero.
Sure, occasionally we can catch a deadly issue in time to prevent something, but more often it is convincing someone to pay attention to their diabetes, or to try an antidepressant, to give them ‘permission’ to put their health above their work, or to create an atmosphere where they patient feels comfortable enough to tell you the truth.
We occupy a place of trust and it is an amazing opportunity that sometimes I forget because it is all I know. I get to see a side of people that is not shown to others. Most of the time it is a very endearing side, occasionally a dark side, either way they allow me in to their worlds and in many cases be a minor hero in their lives.
On days that I am particularly stressed, tired, frustrated. I try reminding myself of the privilege that is given me on an hourly basis. It nearly always perks me up.

02/22/2015 at 2:57 PM Leave a comment

Surgery awaits

It has been a quarter century since I severely injured my knee during a soccer game and it will no longer be put off. Despite a significant amount of weight loss the knee is now worn out and has been impeding my exercise; now it is getting in the way of some of my daily activities. So I am now in the role of patient awaiting surgery.

It is a remarkably uncomfortable role and I find myself second guessing my decision to have a knee replacement. By all logic i have let it go far too long but I keep wondering whether I could/should put up with the pain and instability another year. I find this patient perspective rather educational. I am not worried about a poor outcome, or the anesthesia or the recovery; rather a vague fear of being vulnerable and obtusely being absent from work for the such a long time. I have not missed work for more than three weeks since I was a young man, and the prospect of being out for over a month is terrifying. I am not sure whether I am more scared of being bored or of enjoying my time off.

Being in the patient role helps me understand my patients better; there is a lot to be learned by going through the process; thing that i can use when my patients exhibit the same feelings. Nevertheless it is six weeks until the knife and I find myself conveniently ‘forgetting’ it is looming on the horizon.

Then there are the multitude of logistical issues to handle: informing patients I will be out for a month, setting up a system to run the office while I am away, making sure that patients have sufficient refills on medicines, reassuring patients that the covering doctors are just as capable, etc.

02/18/2015 at 12:18 PM Leave a comment

New Record!

For the last ten years or so the all time record for amount of alcohol consumed by one of my patients (at least what they admit to) has steadfastly remained at one case or beer a day. No, I did not have the presence of mind to ask which beer; I presumed it would be the cheapest available because we are not talking pocket change, we are talking luxury car payment money!
Last month a patient had a rather unfortunate reaction to a very common and benign medicine probably due to the unknown amount of alcohol he has consumed for the better part of his 50 years. To his credit he has not had a drink in over a week ( since his health issues reached a crisis) and he quit tobacco two months ago so he has the commitment to pull this amazing twofer off.
However, he admitted to drinking a gallon of Wild Turkey over a weekend on a regular basis. That is 128 shots of whiskey! the calories alone (9000) are off the chart. I do not know how much he drank during the work week but either way he blew away the previous record.
Considering my age I do not expect this to be surpassed.
How he remains at a healthy weight is beyond my understanding. I have to watch every morsel that goes into my mouth, exercise for an hour a day simply not to regain any weight.
Lucky for him the recuperative powers of the liver are astronomical and if he is able to abstain, he may well have a good prognosis.

02/14/2015 at 12:11 PM Leave a comment

Parenting and baby birds

In my position as a Family Doc I get to see a lot of parenting. Some is just so awful it does not bear repeating. Some is average and unspectacular- sad in so many ways, because with a little extra effort the next generation would be so much more prepared and well adjusted. There is good parenting, although not as much as you would think; where parents are making use of the huge knowledge base to do better than their own parents. And on occasion there is exceptional parenting.

But across all of these parents one of the major pitfalls is the last stage of parenting. What I call- Kicking the bird out of the nest. As opposed to letting it stay so it can shit all over itself. Not every kid is itching for the moment they can leave the house, to be on their own , figure life’s issues in their own particular way. But that is what the goal of parenting is, to mold these kids into self supporting well adjusted members of society. Otherwise you are left with a bunch of dependent parasites.

This part of parenting is so counter to everything else we do, that it is no surprise how many parents mess it up. We are used to taking care of them, watching over them, supporting them.  Over the late teens we should be giving them more responsibility with their increased freedoms but then there comes a time when it is important that they take the training wheels off and go on their own. Whether it be advanced studies, advanced training, or work, they need to learn how to be on their own and eventually to support themselves ( and find out how hard it really is).

Yet time and time again, I will have a parent with a 28 yr old or 32 year old or 22 yr old at home that is doing nothing, going no where, responding to no amount of reason. I must admit I do not understand why a kid would do that ( I was out and gone before the ink was dry on my HS diploma) or why a parent would put up with that, my father pushed my brother out of the house (gently)–He got his Masters in Engineering because of it.

My daughter is leaving for college in a few weeks. It is already difficult to contemplate and it will be very hard and sad. But the idea of hobbling her and enfeebling her by keeping her at home is not acceptable. She needs to fly. So who are the parents looking out for when they do not push their baby birds out of the nest?

The kid may not do well on their own, who knows? But if they stay home we know that will not turn out well.  For reasons that are not clear it does seem that my generation has raised a significant group of dependent, helpless young adults.

PS

I neglected to post this when I wrote it and my daughter has graduated, taught for a year in China and is now settling down with her husband  in Minneapolis. All good things, but I do wish she had found her place in the world closer to home. thanks to the internet and modern communication it sometimes feels like she is just around the corner.

01/01/2015 at 3:18 AM Leave a comment

It’s much more complex than you think

It is not that I am surprised that people don’t know that medicine is complicated, but that they don’t seem to even have any suspicion that there may be alot more to it than they can appreciate.

After all, people do seem to know that med school is long and arduous, yet feel that with even a trivial effort that they can hope to figure out the workings of the body. I see this same effect in many places. It is a denial that the world could possibly be so complicated as to defy understanding or control.

As Isaac Newton famously said ( or was attributed to him) that despite being one of the most brilliant and accomplished minds of his time that he had barely examined one grain of sand on the beach of knowledge.

The levels of complexity boggle even me. The actual knowledge that has already been discovered is so vast as to be humbling if not overwhelming. Much of the time the body’s workings are counterintuitive and inconsistent.

The patient is the undeniable expert on what is happening to him/her as long as they stick to reporting what has happened. When they try to explain why it is so, is where the problems start.

 

as an example: Many times a patient will say something like, I have a headache some mornings, what is it? Sort of like my telling my mechanic, ‘my car makes a noise what is wrong with it?’

It will take me many, specific questions to even hazard a guess.

12/23/2014 at 5:05 AM Leave a comment

Difficult success

This elderly lady came in after recent back surgery. More than that, after her 6th back surgery!! For any one that knows about medicine that is a daunting thing. The success rate of back surgeries drops exponentially with each surgery and after the second or third the success rate is hardly measurable. At any rate that was not the problem. The problem was overwhelming pain two weeks after surgery. Pain so bad that she could hardly survive, could not rest, was in constant misery and nothing gave her any relief.

I entered the situation when the significant efforts of her surgeon became pointless and he sent her to my office. I was shocked (and it is hard to shock me) that she was already on oxycodone 15 mg and she was taking them every 2 hours! That is a hefty dose for someone as big as me, much less a 77 year old lady. Moreover it was barely helping at all, it was not even sedating her. She could not sleep, could not eat, and the pain was effecting her thinking. It took significant effort for her focus on questions, the pain was so intrusive.

I talked with the surgeon to make sure I was up to speed on what he had done and discovered that this was the upteenth surgery on her spine! Ouch! I had the huge advantage of knowing the patient and her husband for decades. They worry enormously about each other and in fact her husband has lost nearly thirty pounds because he cant eat, he is so worried ( and he is very thin to begin with). She constantly worries about his heart and that he will not be able to handle the stress of her problems.

Knowing that narcotics have not helped the pain is a great help, it narrows down the scope of what could be wrong. She felt miserable and complained of pain ‘all over’ so I had to push her to focus on where the sever pain was (started). I finally found an area two inches to the left of the incision where I could feel a series of muscle spasms and she reacted to light presure with significantly increased pain– A trigger point. I decided that the problem we were not dealing with was two fold, tremendous anxiety and worry plus the muscle spasm ( imagine a charlie horse in your back, one that you cant straighten out and relieve). Muscle spasm are nearly impervious to narcotics, I dont know why but that is they way they are.

I first injected her with a hefty dose of Valium. One of the world’s best drugs. Extremely safe when used appropriately, a great anxiety reliever and a very strong muscle relaxer, all in one. I waited 10 to 15 minutes while I prepared a Cortisone injection and then I placed it all around the tender spastic area. All the while assuring her that I would do everything I could to prevent one more sleepless pain filled night.

Within ten minutes her entire demeanor changed, she was not constantly fidgeting, she stopped fretting about the pain, she began talking about how hungry she was, the turnaround, although, significiant was not complete.

There were two additional things, she was worried the pain would return and she began to focus on other issues. I realized that her overall issues were 50% enormous pain 50%anxiety and 50% insecurity. I had only dealt with the pain and some of the anxiety.

Over the next day I continued with the valium, talked to her on the phone to reasure her I was not abandoning her, saw her again the next day and injected a less tender spot that was masked initially but most importantly told her how good she was doing. I pointed out  everyone of the pain based behaviors she had stopped and the abilities that she had not regained. She was standing unaided adjusting her dress! She walked out without discomfort!

Once I got her focus on her improvement and that I would be there for her, She completely morphed into her old self. She had needed to be shown that things were better.

I am happy that she is so much better and now we have a plan of attack should the problem recurr ( and no narcotics!) but it took nearly every bit of learning and experience I have had over the past 20 years, good thing I was on my game that day.

12/20/2014 at 5:56 AM Leave a comment

The danger of Stink Bugs

Monday night an elderly man shows up with an eye problem. He is a sweet man who, despite his age, manages the entire household because his wife is debilitated.
He complains of irritation in his left eye. The story begins with the laundry. Upon removing the clothes from the dryer he notices a stink bug in the drum. He cannot see well enough to notice if the bug survived the drying cycle ( unlikely in my opinion but what do I know?) he picks it up with his hand and brings it to his face to get a good look and see if he is moving when the bug explodes! Into the affected eye.
Luckily his eye only received a little thermal damage and none to his cornea. a few drops, a patch and he was on his way.
My deduction is that the intense heat of the dryer caused steam to build up inside the bug and his shell contained the pressure until he picked it up and put stress on the exoskeleton, upon which a small steam explosion occurred.
The smell was reportedly awful.
Perhaps someone will experiment with the ubiquitous critters to confirm this theory but if so, they will have to steer clear of PETA.

12/18/2014 at 2:57 PM Leave a comment

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