Tuesday, January 31, 2006

Doomed as I am

And I set my heart to know wisdom and to know madness and folly. I perceived that this also is grasping for the wind. For in much wisdom is much grief, And he who increases knowledge increases sorrow.

I sat next to a very sweet couple at dinner tonight. They were probably around 85 each, and at any other time, I would have seen in them the glow that usually surrounds older people, the halo of wisdom, perhaps, and perhaps it only exists in my mind.

But I was starkly reminded of my own mortality today, in a discussion of a patient we're following who is 22 and probably has just seroconverted with HIV. Having dealt with the uncertainty and anguish of a needlestick only last year, I know something of what must be going through her head. Of course, she has gotten herself into this situation by sleeping with "at least 50" (her words) different people and so many of those in the last year that she had to write their names down to be sure. But she is still 22, facing a disease that will kill her, if a car accident or angry lover doesn't first.

And so, seeing the grace of age in two people tonight, knowing that this girl will not probably live that long, was more saddening than enheartening. No man knows his time, but statisically speaking, I'll be lucky to get that old myself. And I'm not even sure I'd want to. I have a warped perspective, working where I do, but in my mind aging is connected with a falling apart, a loss of autonomy, a steady increase in the impositions of others upon your dignity, privacy, and liberty. And I noticed that this sweet couple were eating at this resturant with a nurse, instantly identifiable from her pink cardigan over a flower-print scrub top. I noticed also the thousand little things medical training teaches you to notice. The man's atrophic quadriceps, his cane, and his resting tremor which disappeared with intention. The woman's marked kyphosis, false teeth, and thick glasses. I saw them as patients, or potential patients, rather than as just two more faces in the resturant. Although I didn't realize I saw this until I realized I had started mentally reviewing my BCLS training, "just in case."

It saddens me to think think that, just as I can't look at a phrase written in English without reading it, I now cannot look at a person and not read them. We are told, from day one of medical school, how much the experience will change us, but like Adam before he took the fateful bite, we have no idea what that change means. And having changed, it is difficult to decide whether you would do it again.

What is more difficult is feeling heartbreak with every patient. Sometimes they are funny, sometimes they are sad, but every time I sit back and realize what I am doing, what I am saying, and that they are there because they are in pain, I stagger, mentally.

You have done well to share with me in my affliction.

It is so easy to see the evil in the world. What is hard, and what is my duty as a Christian, is to see that evil and to work for the redemption of the world anyway. Like Beowulf facing down the dragon, I know the fight may claim my life, or my ability to see the world as "normal", or my rest, or a hundred other things I may want, but the fight is required of me. Of me, this is required, because I have the skills needed to accomplish it.

...All this consoles me,
doomed as I am and sickening for death...

I had a conversation with a good friend of mine this evening on this very topic. He is headed into seminary, and possibly to the ministry, and I mentioned that it is very probably the pain we both experience when dealing with the lost and hurting that fits us so well for these professions. So, though our callings cause us pain, still we may say with Job "though He slay me, yet I will trust in Him."

Monday, January 30, 2006

Buy Danish

And since today I'm off the medical theme for a while, I'll just say, buy Danish.

The cartoons that started it all.

A post for eLr

eLr says I never blog about anything interesting, so just once, I'll depart from a solely medical focus to answer her tag.

Four jobs I've had:
Founder, J.A.B. Lawnmowing company (one glorious summer. I was 13, I think)
Email sysadmin (three cheers for Unix, let's hear them!)
Medical student

Four movies I could watch over and over
-The Mission
-Harry Potter (all of them)

Four books I could read over and over (besides the Bible)
War in Heaven
Lost Horizon
The Power and the Glory
The Once and Future King

Four books on faith I could read over and over (besides the Bible. I added this one)
Anything by J.I. Packer
A. W. Tozer's classic More than any other non-divinely inspired work, this book saved my life.
Luther's Commentary on the Galatians
Mere Christianity

Four places I've lived
South Korea
The United States

Four TV Shows I watch (I don't have TV, so, when I do have one)
Law and Order

Four favorite foods

Four places I'd like to be right now
The redwood forests
In a cabin, in the mountains, snowed in, with maybe one really good friend
The Central African Republic, 150 years ago

That's enough self revelation for one afternoon. If eLr can drag herself away from the Gilmore Girls DVDs long enough to read this, maybe she'll be appeased. :P

Saturday, January 28, 2006

What a weird job

I was working in the clinic in a very large, sprawling, office buildling complex when we got a call about someone who had something large and heavy fall on his leg. So, as one of the emergency team, I put on the (huge) first aid backpack, wheeled out a stretcher, and starting sprinting down the long hallways to the scene of the accident. It felt a little odd, wearing a 40 pound backpack, running at top speed down a hallway with a stretcher in front of me, the other medic in front yelling "make way" occasionally. Everyone gets out of your way in that situation, probably (at least initially) more out of a realistic assessment of their chances of surviving the impact than from deference to the red cross on my hat.

For some reason, the excitement of the situation had me smiling to myself, until I realized that was probably an odd face to see on the guy in white running past with stethescope and stretcher.

Tuesday, January 24, 2006

Patients I don't like

There is a mythos surrounding the "patient no one likes" in most hospitals. Attendings tell stories of them in the same manner grandfathers tell ghost stories, and with the same purpose: to excite and terrorize the inexperienced youngsters. But when you actually meet a ghost, or a "patient no one likes," the experience is very real, less exciting, and actually more terrorizing. At least, that goes for the patients, I wouldn't yet know about ghosts.

Today, though, I met the very first patient I don't like. This woman has everything wrong. She is one of the unfortunate souls whom modern medicine can keep alive, and on her own, but just barely. She can't walk well, breathes deeply at rest and is beginning to feel the aches and pains accumulated over seven decades at the bottom of the social order. As is common in many of her socio-economic class though, she has a keen, even overactive sensitivity to condescension. Hence, if I speak to her in layman's terms, she gets disgruntled, and if I use medical terminology, she won't understand and feels I am "acting better than her." The encounter was doomed from the start probably, but things got really sour when I insisted (rookie mistake) that West Nile Virus does not, in fact, cause weeping ulcers on a person's ankles. She told me "well I beg to differ young man, because I wear white socks." At this point, I think the quizzical expression I was wearing said far more than my meek question about what white socks had to do with West Nile. She elaborated "I need to wear them because of the things West Nile puts on my legs. They get worse in the spring when there's more West Nile around. The doctor gives me something for them then."

Here is where the Zen Master is practising the art of medicine so well. Instead of countering her, which leads no-where very quickly, he has prescribed her a harmless lotion for her sores. This does actually treat them, and though she remains convinced she has "West Nile legs" she gets treatment despite her error. He emphasized to me the importance of never telling a patient like this anything you aren't positive on, because at some point in the past, someone told her she has this condition, and she has latched onto it as an explanation for what she can't change about herself. The real reason for her sores is that she has diabetes, has smoked for 60+ years, and has ruined the circulation in her legs. But the "West Nile cream" is all she really needs at this point.

The Zen Master is a really good doctor. Despite his unassuming manner, his constant mention of what he doesn't know, and his cynical commentary about patients like this, he considers closely the cost of what he orders, he considers the patient as a whole, and he takes into account the quirks of human nature. And he is always learning new ways to improve.

Sunday, January 22, 2006

Balance is a concept necessary to life which is probably over-discussed, and under-considered by medical students. I recently have been doing a lot of thinking on how much I've let my studies, and my work, take over not just my time "at the office" as it were, but my life outside too. What is most disturbing is how much of the thinking I used to do I am now too tired to entertain.

When I considered life after college, I thought about two paths. One, to medical school, and the second, to seminary. Because, while I've always been good at science, I've always felt a deep spiritual conviction. And even when I've tried to subsume this conviction for various reasons, G-d will not be ignored. Why I didn't go to seminary is primarily that I didn't feel a real call to that, and though I knew a lot of theology compared to most of my friends, and enjoyed it a great deal, I've never been very good at communicating it in practical ways. I've always felt that spiritual communication requires some degree of openness on both sides, and a natural introversion kept me from doing this well. Though I may have been wrong about that, it is decidedly the case in medicine that no openness at all is required of the doctor. Sure, interpersonal exchange is part of the encounter, but that isn't what I mean. A doctor, I supposed, was to listen impartially and make recommendations and decisions. Additionally, I've always been pretty obsessed with wanting to know exactly the right answer, and the advisors I had my junior and senior years in college were of the mind that a minister must be much more open-minded than a physician, and much more willing to deal with uncertainty. I think they were probably poor advisors in that, and spoke largely from inexperience with either the true G-d, or with medicine.

The long and the short of it is, I've recently realized how much I miss the meditations I've neglected. For there is only one way to keep sane in this world, and life in the hospital is nothing if not more intense than life outside. For there one is faced with all of life and death and the human experience of suffering, constantly. At any one time, there is rejoicing and there is agony behind the doors marked with a caduceus. As someone who empathizes easily, this can be greatly affecting, and I've noticed that to deal with such stress, I can either shut it out, or embrace it with the realization it is part of the curse humanity has brought upon itself and the world. Only one of those options is healthy in the long term.

But it isn't just the stress. Part of the problem is that I got into medicine because I love learning of all kinds. And medicine is infinite. You can never stop learning, and you can't afford to. So both positive and negative reinforcement are at work here.

At some level, I'm not sure "balance" is what I should strive for though. It seems to me that if G-d is Who He Is then He demands everything. And medicine being what it is, it demands (almost) everything. And I can't split my time 50% medicine, 50% G-d, if that were even possible. There must be a way to serve G-d through medicine, and so, according to a long history of Protestant theology, there is. It is just making that theology real which is bothering me at present. However, I also don't have the energy or time to act like a seminarian. Additionally, that would be abrogating my responsibilities in the position to which G-d has called me. Every situation which requires thought, it seems, is also of the kind which takes up any time you might have for thought.

Tuesday, January 17, 2006

Quote of the Day

The quote of the day, from a presentation by a fellow med student. I can't tell if it is only because I'm here that I find this so funny:

"As far as medical history goes, I'm not sure this matters, since he's had the leg amputated, but he did break his ankle about ten years ago."

Wednesday, January 11, 2006

I really am a nerd

I just finished writing up a history, physical, assessment, and plan for my preceptor on one of my patients. The really sad thing is that I enjoyed it. I can't think of another time I've written a research paper at the last minute, used ten references, stayed up past my bedtime, and still enjoyed myself. Wow. I thank G-d for putting me in this place.

It's the only way a nerd like me can survive, thrive, and even be thought of as halfway normal by the populace at large. That still might be too much to hope for in my case though...

Tuesday, January 10, 2006

Every step of the journey, is the journey

Today, while working with a new attending (I'll call him the Zen Master) in general medicine clinic I had more autonomy than ever before. With three of the patients I saw, I came back to the Zen Master's room, presented my findings, told him what I wanted to do, and he said "ok" signed the note, wrote the orders, and told me to send the patient on their way. Granted, there are uncomplicated complaints, but it still is fun to reach that stage of proficiency and trust.

The Zen Master is also a great teacher. When a patient was late, we sat down and discussed some articles from the New England Journal, he quizzed me on algorithms for the work-up of various complaints, and he expressed his own philosophy of medicine. I think the letters "M.D." after a person's name predispose them to philosophizing and solving the world's problems on the back of an envelope. Although I'm probably already there without the letters. Maybe that kind of person just goes into medicine.

Dr. Woodley also had some great comments when I ran into him today. He said "People read these [scientific] papers like they're gospel. They're so far from gospel I can't even begin to tell you." And then later he pronounced: "Medicine is not for the brilliant. In fact, anytime you find a brilliant doctor, make sure his nurse practioner is real compulsive and attentive to detail. Brilliant people are liable to be absent minded and hurt people." Priceless.

Monday, January 09, 2006

It's not always about pills

Today I was reminded that medicine is not entirely about pills, and not entirely about sickness. I was in the cardiology clinic, wrapping up a patient encounter with my attending. It hadn't been a difficult one, the guy is pretty healthy, and was only in the clinic because of a scare over an abnormal EKG, which he had only gotten because he was participating in a study. He works in one of the clinics downstairs, and this was his follow-up appointment. Asymptomatic sinus arrhythmia, not going to bother him. He had managed to stop drinking alcohol, which had been recommended the last time he was in and his only request was to get the nicotine patch. But Dr. Woodley did something quite interesting. Their conversation went as follows:

"I think you can stop smoking on your own. But what is really important is that you leave here and improve yourself. Go out an get an education. The military will pay for it, go get a degree"

"I know, I'm trying, but night classes are hard"

"Yes, thank you for reminding me that life is hard. Go get an education, and don't come back here unless it is to brag to me. I'd love to see you for that purpose"

Later that day, Dr. Woodley was telling me how to take a history (a favorite subject for attendings talking to med students) and he mentioned that the most important part of the history was the social history. This surprised me. More important than knowing about chest pain, dyspnea on exertion, past medical history, surgical history or anything, is knowing whether a patient is married, whether they have kids, whether they smoke, drink, have any hobbies, go to church, etc. Amazing.

This evening I was telling a friend how interconnected the cardiac system is. How the heart is affected by the kidneys, by the liver, by the lungs, by the brain. Cardiology then, (like most of medicine but perhaps more so) requires a knowledge of every part of the body and how they affect the system of primary concern. And the holistic approach evinced by Dr. Woodley's advice shows that far reaching concern.

Finally, Dr. Woodley said something which sounds at first like a compliment, but is more a statement of philosophy. He said "What's the best thing to happen to medicine? You are. Never forget that."

Thursday, January 05, 2006

Maybe it's silly, but...

I showed up to my walk-in clinic today, and got a fun surprise thrill. I have my own office, with my name on the door. I feel more like a professional all the time.

Wednesday, January 04, 2006

More patients

So I finally got back into the clinic today, and though I got off to a rocky start, it went well. Since this is rheumatology, my patients were fairly typical. I saw a woman complaining of pain in her joints to start the day, and with some careful questioning, elicited a diagnosis of Sjögren's syndrome. The next patient was having similar symptoms, but mostly arthritic, with no obvious keratoconjunctivitis sicca, so we settled on just saying she has rheumatoid arthritis with some concerning blood work. She'll need regular follow-up, but for now she gets Tylenol and eye-drops.

The last patient was a procedure. He's got a Baker's cyst, a swelling at the back of his knee which causes some pain with walking. So the treatment is to enter the knee from the front with a large needle (after anesthetic, of course), drain out what you can, and re-fill the space with lidocaine and steriods. (The lidocaine numbs the area acutely, and then the steroids reduce the inflammation in the long term. It works beautifully.) After Dr. Sears numbed up the area, I got to do the rest of the procedure. It can't be a pleasant one under any circumstances, but I mangaged to pull if off without causing unnecessary discomfort, and my attending was pretty complimentary. About the entire day, actually. He said I did a great job getting the histories and physical exams, and (in a fairly typical attending move) tried to convince me that rheumatology was the way to go for a specialty. All in all a great start.

Rheumatology might actually be a lot of fun. It is a solely clinic/lab specialty, so you can't get called to the ER late at night because Mrs. Jone's has had a flare of her arthritis. And so the hours are great, and, according to Dr. Sears, this is great for a family. I don't presently have that concern, so maybe I'm not as wise as I might be, but the siren song of cardiology still calls to me.

Next up, walk-in clinic, pretty much where you go if you don't need the ER, but can't wait a week. No idea what I'll see, but the attending doesn't know either, so I'm not at too much disadvantage there.

But yes, the rocky start I referred to above. You know how sometimes the word, phrase, or question you need is just at the tip of your tongue? Now extend that to an entire conversation. I clean forgot what questions to ask, how to write down my findings, everything. I was writing a SOAP note like an H&P. Horrors. Of course, this is medicine, and it is easier to get away with that, but I was having flashbacks to Surgery, and heard Dr. Harb's voice saying "Stop using complete sentences, Nathan. I don't want complete sentences." I survived though, thanks to an understanding patient, and some appropriately timed thoughtful pauses.

Tuesday, January 03, 2006

And so it begins

First day of Internal medicine today. Mostly orientation, getting new schedules and the like. The first six weeks will be in outpatient medicine, with different clinics and preceptor meetings. Just keeping all the requirements for my presence straight will be a challenge.

I am quite excited that I will be working in Cardiology one morning a week, and that my attending for that won the "best teacher" award from the class which graduated last summer. It will be quite difficult, I imagine, but ultimately rewarding. Tomorrow I start off with Rheumatology, and it looks like I'll be working up a patient who may have lupus, followed by an older man with knee pain. According to Dr. Sears, that may net us a procedure, which should be fun.

So overall, I've got one morning of cardiology clinic, one morning of rheumatology clinic, one morning of walk-ins, one morning of general medicine, one full day at a satellite clinic, two afternoons with a preceptor discussing papers I'll write, and two free afternoons. Not a bad schedule.

So far I am concluding that internal medicine guys are far, far nicer than their surgical collegues. Dr. Sears called me in, showed me the schedule for tomorrow, told me what to read, and offered to meet half an hour before clinic starts to give me a run-down on what to expect in my first patient. The focus is on learning and teaching, and they are excited to help the process along.

Monday, January 02, 2006

Into the Flourescent Tomb

I borrowed part of the first season of Scrubs from a friend today. It's the first time I've seen it, and yes, I am way behind the times in that. An amusing show, not always great, but giving a pretty good picture of life in the hospital.

Rotation 5 starts tomorrow.