Development

Nhi Dong I (literally children's hospital 1 in Vietnamese) seethed with humidity, crying children, and stoic families. The corridors colonized with cots and tents, clothes hang drying in the absent wind. The ICU, as it were, stood behind a curtain, with individual beds and incongruously modern monitoring equipment marking it as the domain of the truly worrisome. I stood head and shoulders above it all, unable to follow the oscillations of foreign speech, physically removed by my alien shape, size, and coloration. I was there, theoretically, to learn and to teach, to bring my foreign viewpoint and education to work with the local pediatrics residents for four days out of a month otherwise spent in a cool office space, researching newer and better ways to promote helmet use. I sat down with my partner to hold clinic, his rapid fire interrogation in Vietnamese and 30 second physical exam directly in contrast with my slow translated questions and protracted study. His throughput was nearly quadruple of mine, and given the remarkable size of the line waiting as we broke for lunch, the reasons why were obvious. One side of my brain wondered at the brevity of his exam, the fact that there is no way he truly hears anything through his stethoscope in the amount of time he listened. The other half marveled the fact that all his poor form, the discrepancies in what I believed to be a truly good exam and what he performed, and he still arrived at all the same conclusions, all the same diagnoses and treatments. The diseases ranged from the familiar to the bizarre, and I left the day tired, sweaty, convinced that I was definitely going to get Dengue Fever while in Vietnam, and intrigued by the skill and savvy with which my Vietnamese colleagues had overcome their disadvantages in education time, resources, equipment, and ancillary support to provide care well beyond an american provider in a similar position. It left me to wonder, what was the merit of our protracted education? Why did we need 8 years of higher education, of which the majority of the final year was spent doing educationally questionable things like going to Vietnam and eating copious amounts of noodle soup. What had all my training and experience provided me that he didn't have? The answer, in the end,comes down to systems. A system like Nhi Dong, built on throughput and insane numbers of patients, leaves no room for higher level thought, for making that "great catch," or the "tough diagnosis." The numbers just don't pan out, and the system lacks the money, the doctors, and the space to truly investigate a difficult case. American Physicians are trained the way we are because we are expected to operate at a higher level, to be perfect in a way no human being truly can be. We are meant to think critically, to assess the whole of each patient, to move beyond complaints and systems to a practice model in which each patient can receive the whole of your attention, to where you can make that critical early catch, and start treatment before there is even a problem. This training is inherent in the entire model of our education, and is probably why so many of us have so much trouble facing real-world practice models. We hate the fact that you can't have our whole attention, the benefit of 20 odd years of education. We hate that even in the resource-rich United States we are still stuck with issues of access, throughput, and time.

Malignancy of Youth

She sat primly on the exam table, ignoring the indignity of the thin gown with an air of casual familiarity. An older woman, she was not at all put off by two men in white coats, despite her lack of attire. She was here for a complaint of repetitive vaginal bleeding, a phenomenon typically standard for the female of the species, but not at the advanced age of 65, not 14 years after her menopause. We probed for details, asking about volume, frequency, color, consistency. She had undergone an endometrial biopsy, which came back anomalous, not for cancer (our biggest concern in this situation), but for its health, a far more well developed endometrium than should exist in a post-menopausal woman.

We took another look with the speculum, examining her in the indignity common to the needs of feminine health maintenance, and again found anomaly in her health. We found health, abundance, a complete lack of the atrophy that is the stigmata of age. We asked further questions, attempting to get to the bottom of this mystery. She reported no pain, no nausea, no vomiting. In fact, the only difference she had noted was a tightness in her bra. Stumbling over words, she noted an increased "perkiness." A breast exam was inconclusive, yet another finding notable only for its overstated health.

We walked out of the room, the resident and I, stumped by a bizarre presentation. The standard treatment for dysfunctional uterine bleeding (which we presumed this to be) was a dilatation and curettage, the literal scraping of the uterus clean. We walked back to present to the attending with this idea in mind, only to find an less than receptive audience to this plan. The word malignancy came up, a granulosa cell tumor that revives the lost and forgotten estrogen key to endometrial growth and menstruation. An ovarian malignancy that has different effects at the extremes of life, serving as a rapid introduction to puberty for young girls, and a sexual fountain of youth for older women. Estrogen increases breast size, maintains menstruation, and prevents vaginal atrophy, and this malignant packet of cells had provided a fountain of youth in a faustian bargain ultimately ending in death if untreated.

We went back in, planning imaging and an eventual laparotomy to remove the disease. We discussed the situation with the patient, who lowered her silvery head to consider the situation. When she looked up, a mischievous smirk stole across her face, and she asked "is there was any way to keep the big tits?"

Turn away

Medical School in the modern era has undergone a metamorphosis in how it deals with "feelings."  Gone are the days of total repression and stolidity, replaced instead with an overcorrected idea that it does us some service to explain to our professors (who are just as poor at reading papers as most scientists) how some of the horrors we see make us feel.   Most specifically I was asked to reflect on a series of videos and articles discussing the horror that is human trafficking, specifically children, and specifically sex trafficking.  While it doesn't fit the vein of most of my normal work, I thought it worth putting up.   (mostly for my forty year old self to marvel at my righteous indignation once I am suitably jaded):  (sorry for what is most likely a substantial lack of editing)

The hardest thing to face in my medical education has not been illness, has not been disability, has not been mortality.   People get sick, they get crippled, they die.  Often these events are direct consequences of life decisions the patient made to their own benefit or detriment.  This is an impersonal war to fight, doctors vs disease, the human equivalent of building dikes to keep out a rising sea.   The hardest thing has been the evil, the raw, visceral darkness that afflicts our species, the casual cruelty that brings abused children to our ER, gun shot wounds to our OR, and the ignored and deathly ill elderly to our palliative care.   It is hard to think about.  It hurts to think about.   Without fail ,when faced with the reality of abuse, of neglect, of vicious intentional evil, I want nothing more than to retreat to my bunker of middle class comfort, where my kind and patient parents treated me with nothing but love, and shielded me from the dark vicissitudes of mankind.   I can, and have, wallow through spurting arteries and disconnected body parts in the OR.  I can watch people die, feeling nothing but compassion and a desire to help.  But I squirm and twitch when made to look upon belt and burn marks on an innocent child, when asked to watch videos of helpless children forced by an uncaring world to advertise their skills at oral sex.  

Human trafficking, for instance, is the sort of problem that makes me want to curl up and hide, to withdraw from the position I have long sought as one of the people who makes things better.   Huge and intractable, it is a monolith of sin and depravity that is hard to even think comfortably about, reflecting as it does the darkest parts of human nature.   One shrinks back it, loath to try to understand how it is that members of your species engage in something so soulless, cruel, and disturbing.   On a personal level, I have no response to this issue.   I can’t even deal with it without resorting to defense mechanisms, the intellectualization and derealization that protect me from the considerable pain of empathy with the millions of children right now being torn apart by greed and sickness of adults who were meant to shelter and raise them.   In a way, those defense mechanisms are what you ask me to employ here.  The dry context of how this information will affect my practice is a well-meant question, designed to raise the issue in my mind, to encourage me to help.   But I find it hard to answer, each thought, each theory, about how I can help falling flat in the face of the sheer volume of pain.  

I could talk about the policy of it all, of the overarching need to drain the swamp, to promote education, civil society, and local development in order to eliminate the crushing poverty and insecurity that provides the source of so many of these slaves.  We could push for increased enforcement of laws, for political and economic pressure on the countries most known for being purveyors of sex tourism to enforce common international rules.   I could promote local efforts to track down the operators of local brothels and the kidnappers and slavers who run them.  I can make high minded policy arguments about legalization and regulation of prostitution in order to ensure that only the 11% of women who don’t want out remain in the business.   I could talk about the increased vigilance I will employ in my practice, looking for signs of abuse, asking questions no matter how painful or rude.   I can talk about how I will be involved in physician lead efforts to improve healthcare for sex workers, to mitigate the pain and destruction that this life inflicts on them.  Of course, I could state my intention to provide money and support to organizations that help rehabilitate the victims.   All of these are good ideas, all of these can help some of the 27 million people living in shackles, literal and metaphorical.   Any of these is a valuable use of time, effort.  But none of these changes what is happening now.  None of them changes the vast quantity of wrong that touches my life only tangentially.  None of those efforts improves the life of a Filipino woman held hostage by two disgusting examples of our profession in our own state.  None of these efforts wipes clean the stain of  seemingly normal people using  craigslist, the internet, cell phones, and the comfortable framework of modern American life to repeatedly rape a 14 year old girl in a motel I drive by every time I fly out of Milwaukee.  Even the discomfort, the cringe that I feel when talking about the issue seems a mockery of what those afflicted by this blight are going through. 

The one thing I can do right now, for those currently in pain, is to bear witness. To be stronger than my weakness, than my avoidance, and to recognize both the sin in the world and my, and our, current failure to solve it.  Of course I will resolve to work in the highly unsatisfactory and slow effort to fix these problems, to fix whatever it is in humanity that lets us do this to a subset of our children.   Of course I will be vigilant in my practice, and I will give money and time to efforts hoping to resolve, if not this problem, then others that bear on it.  I will use my knowledge and energy to promote policy helping the third world and impoverished areas of our own nation to grow out of the diseased poverty that spawns issues like this and so many others.   But most importantly, I will recognize this evil abroad in the world.  I will care about its victims as much as I can.  I will not shy away.  

 

Patience

Wild hair flying, sullen eyes narrowed, the overweight woman barreled through the hall on her motorized wheelchair.   She left the floor every day to smoke, fleeing her hospital bed for he relief of nicotine.   Her body had ravaged by polio, caught in the last gasps of the disease before the herd immunity of an immunized body politic saved almost all US citizens from the ravages of the disease.  She had diffuse neurological damage and was barely able to walk.  The polio combined with the stress of 50+ years of partial mobility to create diffuse and excrutiating pain.  She had been on immense quantities of painkillers for years, and had developed an opiate resistance to rival that of Keith Richards.  

She was here for no particular reason.  Her pain had acted up, fall storms driving her to seek solace at our hospital.  She had health issues enough that she could always get herself admitted, tearfully pleading for someone to fix her.   She got sullen every time, blaming us for not trying, for not helping.  Pleading evolved to a more strident beast, eventually culminating in demands for a neurosurgical procedure that she felt CERTAIN would fix her pain.  She ranted about her family, a victimization complex seeing every slight as a salvo in an orchestrated campaign to put her into a home.  She demonized the public health service, declaring her need for more than an hour a day of government sponsored home assistance.   She lectured us on our hard natures, blaming our inability to meet her demands on the fact that men never respect women.  Every day I saw her was a struggle, trapped in a room with a person whose struggles I felt for, and whose personality defied affection.  

She had disease, but her pain was magnified tremendously by her inherent depression, and her cultural biases shot our treatment plans in the foot.  She refused all the practical suggestions.  I spent hours talking to her, convincing her that chronic pain like hers is not curable, that there is no surgery,  no pill.  I reinforced that her opiates were maxed out.  I suggested trying medications like neurontin and amitriptyline, both of which could have helped her pain (and amitriptyline her depression), only to have these suggestions rejected because, of course, "I ain't crazy."   In a similar vein she rejected any suggestion of assistance from chronic pain psychologists.  

It came time, after a week, to discharge her.  We tried earlier, but were met with strenous resistance, accusations of not caring, threats of complaints and lawsuits.  The hospital, by nature a risk-averse institution, elected to let her stay until her coverage ran out, adding thousands onto an already astounding bill she was never going to pay.   When finally we called security to escort our most trying patient out, we were met with a barrage of profanity, and a week later, two malpractice complaints (the first of my career). 

I didn't like her.  I didn't like her because she wouldn't let us help her.  I didn't like her because she didn't like me.  I didn't like her because she was a waste of precious healthcare dollars.  I didn't like her because she was just intrinsically not likable.  I don't think she taught me any lessons (outside of showing me a post-polio syndrome, which is fairly interesting).   I have no great insight from this episode.  I didn't care for her, and I did my job.  I tried to help a demanding, uncaring, selfish disaster zone from hurting herself any more.  Because thats what I signed up for, and thats what this job is, and for every delightful person in the world, there is one like her, and they all deserve our effort.    

Those Eyes

My girlfriend's response when I informed her of the role of fungus in seborrheic dermatitis (aka, Dandruff) reeked of incredible disinterest.  "Really?" she asked me, with an incredulously malicious glint in her eye, "that's common knowledge to anyone with a beginner's understanding of hair care."  Despite my argument that this means approximately 1/2 the world's population is completely unaware of this phenomenon, I still had been thoroughly put in my place as late to the scalp health soiree.  She regaled me with a robust explanation of why dandruff shampoo included selenium, an active ingredient that disrupts fungal cell cycles.  She lambasted my poor understanding of how to keep a scalp healthy and flake free.   She gave me the treatment that I usually reserve for all my otherwise intelligent friends when it comes to healthcare. All this she did with a look in her eye, a patient but condescending look that I imagine I wear all the time.   Man, do I hate that look. 

The long and short of the facts of dandruff is that it results from a persistent fungal skin infection causing seborrheic dermatitis, a fatty flaky rash that generates the pseudosnow dappling some of our dark shirts and jackets.  The shampoo's and medications used to get rid of it are all antifungal in their function, and the one real take away message is that you need to rotate your antifungal shampoo in order to fully clear a fungal infection, as they will grow tolerant to monotherapy with head and shoulders (active ingredient: selenium). 

But I knew none of this.  It wasn't covered in my pathology class. I had heard of seborrheic dermatitis, but only in connection to HIV (which increases the incidence, as if HIV patients needed the insult of dandruff on top of the injury of HIV).  We don't educate well on the annoyances, the minor medical mysteries and problems that confound people on a day to day basis.  You pick that up in residency, in practice.  On that fateful day my girlfriend taught me two lessons.  First, a strong preliminary course in haircare.  Second, a lesson in humility.  Next time I give a patient or a friend a lecture, it will definitely come from a place of better understanding.  

Push

He sprawled on his hospital bed in the shadows, a 17 year old boy trapped in a body that combined the worst features of gangly youth and old age.  He had the eerie look of a body that had not withered away, but failed to ever grow.   In the dark he desultorily watched TV, a sneer on his face and a distinct lack of enthusiasm writ small in every move of his body. His disease had held him back at every stage of his life, stunting his growth, forcing him into hospitals instead of school.  He has crohn's disease, an auto-immune debilitation of the intestines.

He has been in the hospital for three months already. We have tried everything, from steroids through genetically engineered antibodies to attack the inflammatory factors riling up his system.  We had long since moved on to experimental treatments.  His current attack is brutal, and when he is off the toilet enough to let us examine him, we see signs of only worry.   This attack is strange, eschewing the normal focus on the small intestine, zeroing in on the colon.  Its weakened, and we worry that he is at risk for a rupture, for the dreaded peritonitis with its risks of death and debilitation.   We are concerned that he could develop a condition ripped straight from the title of a B movie: Toxic Megacolon.   For all his diarrhea and pain, he is still holding residual volume.   In the spirit of the B movie, toxic megacolon has a distinct limit, a line across which if we pass, lies only disaster. 10 cm.  10 cm dilation of the colon, and he is at risk for popping like a feculent grape, for dying feverishly, destroyed from the inside out.  

He needs surgery.  He needs controlled removal of a chunk of his colon, a surgery that leaves the possiblity of re-attachment and normal function in place for later.  The surgery will, for right now at least, cure him.  It will also leave him with an ostomy, his life even further removed from normal.  He resists, he pushes back.  Every day for him is guerrilla warfare against his physicians.  He demands different meds, he antagonizes providers, and refuses to let nursing staff weigh and help him.   Its all for his own rage, and for the one man audience of his father, the one who gets to make all the decisions.  He fights for a normalcy that has been denied him, for a fairness he has never known.  We can't help him against his father's will, and his father wont help him against his.   So we push, and he pushes back harder, and we hope against science and experience that we are wrong.  

Garbage

I marked the leg at one thirds and two thirds of its distance.   I drew a roadmap for our sharp implements, our knives of metal and electrocautery.  In silent curiosity, I watched as the gowned and gloved man applied a knife of furious electricity to the skin, burning through it in the quick of a blinking eye.   He cut down to deep, exposing the rust filled sartorial red of relatively healthy muscle.  Moving the tool with deliberate ease, he marched along the map I had drawn, etching it out in eerie relief.  

Pulling back the flap of skin so recently relieved from its tense duties, we expose muscle, cutting and detaching until the bones are visible.  They hand me the instrument, a giant parody of garden shears, meant for cutting of thin bones (of which the fibula counts).    A slow alignment, and I have the bone in my grip, tenderly squeezing the shears.   My touch does nothing, and I slowly increase the pressure, eventually squeezing with all my strength until I hear a crunch both satisfying and revolting.  

"Good Job," notes the Fellow, regaling me with scarce praise.   "Now saw through the Tibia."  He hands me a loop of sharp toothed wire, a Jigglysaw, the jigsaw in miniature.   In my best impression of a ghoulish lumberjack, I saw through the thicker tibia.  The others are clamping and burning bleeds, the sparks of their electrocautery refracted in a spray of white bone chips.   With a lurch, the saw come free.   The Fellow picks up the leg and hands it to me.  

"Get rid of this."

I stand there, momentarily bewildered.  I hold the leg firmly, the business end of fragmented bone and gore facing firmly away.   I'm meant to get rid of it.  I have no idea how.   The circulating nurse is holding a giant biohazard bag for me, a clear invitation to dispose of my post-apocalyptic zombie trophy.   I have a momentary flash of incongruity, and I throw the leg in the bag.  The nurse walks to the trash, and throws it out.