I spotted her in the waiting room. Her hair sat neatly made in a French twist, smooth bangs parted on her right. She wore blue cargo pants and a green sweater, and she was reading a book on Baruch Spinoza. What was she doing in my medical clinic?
Most of my patients arrive to clinic in a state of chronic or acute illness. Many of them are appropriately dressed, but they look sick. Many of them are in constant pain. Some of them want their fix, their benzodiazepines or their narcotics. Others just want their blood pressure medications refilled. This is not to say that the average decent human being who is a patient in Resident Medical Clinic and who happens to be homeless, uninsured, or disabled can't also look fabulous.
However, I have yet to catch any of them reading a book on one of the most compelling and complicated philosophers in history.
"Hi."
"Hi."
"I'm Chloe. I'll be your physician today."
"Lindsey. Nice to meet you."
"So."
"So."
"What can I help you with?"
She explained her problem with occasionally seeing blood in her sometimes liquid, sometimes formed stool. I quickly settled into my comfortable medical place where there is one complaint and I can beat it to no end with specific, detailed questions, until--
"I don't really remember my 20's." [Laughs.]
"Really? Why not?"
"I was smacked out on heroin."
[Silence. Not many jokes I can make about heroin. She smoothes the front of her sweater.]
"I guess that's why I'm so jittery now," she continued.
"Right. Are you still doing..."
"Oh, NO. Nonono. I was on Methadone and Suboxone, now I'm completely clean." [Smiles]
I knew that was coming. The interview was too easy up to that point.
The rest of the history-taking went well. She seemed pleasant and sincere. She brought all her medications. She knew her allergies. She's been trying to get her masters in Philosophy at a local college, but she had to quit her job the week prior due to unending and embarrassing diarrhea. I worked up malabsorption and wrote a referral to the GI folks down the hall. Her mother has a history of ulcerative colitis. She might need a colonoscopy.
The plan was set. I felt like I knew what I was doing. I even had a full fifteen minutes before my next patient, then--
"So the GI Clinic will call you with an appointment. Is this your correct phone number?"
"Yes."
"I noticed it's in another state. How long did it take you to drive here?"
"Umm, about and hour and a half. Not that long."
"An hour and a half?"
"Yeah, I just didn't want my boyfriend to know I was coming here. "
"Oh, why not?"
"Well, he's kind of controlling."
"How so?"
"He yells sometimes. And he restricts my allowance. Since I can't work, I get an allowance from him."
"I have to ask you--"
"Does he hit me?"
"Yeah."
"Sometimes."
I remembered seeing bruises of various ages on her hip, arms and legs. She told me just minutes ago they just appeared out of nowhere, that she must have bumped into things at work or at home. How did I miss the possibility that their etiology could have been something other than what she was telling me?
After a long sob, the patient smoothes the part in her hair and buttons the top button of her sweater. She shakes my hand and promises to get those lab tests I ordered and make those appointments I recommended and to see me again in a month.
I haven't seen her since.
Sunday, July 30, 2006
Early Satiety
Welcome, old and new readers and friends! Thank you so much to my loyal readers for your encouragement and kind words. I'm glad to be writing again, and I'm so touched you've continued to read my work.
[[[]]]
Early Satiety
"I’m getting fat! How do I stop gaining all this weight?"
My patient throws her thin arms into the air and looks at me. Her abdomen sits rotund, larger than a 42 wk pregnancy, and her sleeves are loose and parachute-like. She tells me she used to be able to eat four hamburgers; now, she can only finish half of one before she feels full. At night, she can no longer lie flat without becoming short of breath from the weight of her insides pressing on her. She is 66 and has not had a period since the 1970’s. She has a history of breast cancer, status post radiation and mastectomy. She also had a vaginal hysterectomy for fibroids, and she opted to keep her ovaries.
In addition, she is a wonderful person. The nurses and CNA's love her. A regular in the Resident Clinic, she and her husband collect Social Security and Medicare, and the Clinic is situated conveniently on their bus line. I might be the fifth resident to have her in my three-year long Continuity Clinic.
"Good Lord, look at me! What is the deal?" she says, wiping the sweat from her brow. She's been easily tired. The weight started to pile on quickly in the last six months.
When I present the patient's case to my clinic attending in a nearby lounge, he shakes his head. "The nice-person, negative-prognosis sign," he says. I nod. I know what he's talking about--mean patients tend to be less likely than the pleasant ones to pass away.
I filled out a lab form that included a CA-125 and a CT scan of her abdomen and pelvis, in addition to an array of other serum levels. I walk quickly back to the room and tell her we are looking for something that may cause all this fluid.
"Like what?"
"I don’t want to alarm you."
"Like another cancer?"
"We’re not sure. We want to be sure."
"Isn't it all just fat?"
"I don't know. It could be."
"I mean, look at it!" At this point, she grabs her belly and tries to lift it off the chair. I try not to laugh while she shakes her head and lets out her own laugh, then a sigh.
"OK. Do what you need to do, Doctor. Just make sure Medicare covers all this."
I wondered to myself, if I hadn’t been an intern in OB/GYN for a year, if I hadn’t seen all those women with ovarian cancer, their abdomens sometimes so filled with malignant ascites they couldn’t breathe at night, would I have come to the same conclusion about the patient in front of me, in a general medicine clinic?
I hoped, Maybe it IS all a pannus. But the fluid wave. I couldn’t ignore a fluid wave. Her abdomen seemed to grow exponentially. It had to be ascites, but why? Her lungs were clear. A recent ECHO showed no evidence of heart failure. A set of liver function tests from last year was normal.
The last patient I took care of with ovarian cancer lived and died during my first internship, on my rotation in Gynecology-Oncology. I can still remember what her cries sounded like, and what her smile looked like. Her case infused my thoughts even when I was at home, though I tried not to let it. I knew it wasn't wrong to feel things while at work, but I didn't want to feel too much. I didn't want my emotions to hamper my job.
Seeing this new patient in front of me, this funny, pleasant, kind woman who brings her health to me and asks me to help take care of it, I know it is useless to hold back. If what happened to me with the previous patient repeats itself, then let it. If it hampers my job, it might also make me a better doctor.
[[[]]]
Early Satiety
"I’m getting fat! How do I stop gaining all this weight?"
My patient throws her thin arms into the air and looks at me. Her abdomen sits rotund, larger than a 42 wk pregnancy, and her sleeves are loose and parachute-like. She tells me she used to be able to eat four hamburgers; now, she can only finish half of one before she feels full. At night, she can no longer lie flat without becoming short of breath from the weight of her insides pressing on her. She is 66 and has not had a period since the 1970’s. She has a history of breast cancer, status post radiation and mastectomy. She also had a vaginal hysterectomy for fibroids, and she opted to keep her ovaries.
In addition, she is a wonderful person. The nurses and CNA's love her. A regular in the Resident Clinic, she and her husband collect Social Security and Medicare, and the Clinic is situated conveniently on their bus line. I might be the fifth resident to have her in my three-year long Continuity Clinic.
"Good Lord, look at me! What is the deal?" she says, wiping the sweat from her brow. She's been easily tired. The weight started to pile on quickly in the last six months.
When I present the patient's case to my clinic attending in a nearby lounge, he shakes his head. "The nice-person, negative-prognosis sign," he says. I nod. I know what he's talking about--mean patients tend to be less likely than the pleasant ones to pass away.
I filled out a lab form that included a CA-125 and a CT scan of her abdomen and pelvis, in addition to an array of other serum levels. I walk quickly back to the room and tell her we are looking for something that may cause all this fluid.
"Like what?"
"I don’t want to alarm you."
"Like another cancer?"
"We’re not sure. We want to be sure."
"Isn't it all just fat?"
"I don't know. It could be."
"I mean, look at it!" At this point, she grabs her belly and tries to lift it off the chair. I try not to laugh while she shakes her head and lets out her own laugh, then a sigh.
"OK. Do what you need to do, Doctor. Just make sure Medicare covers all this."
I wondered to myself, if I hadn’t been an intern in OB/GYN for a year, if I hadn’t seen all those women with ovarian cancer, their abdomens sometimes so filled with malignant ascites they couldn’t breathe at night, would I have come to the same conclusion about the patient in front of me, in a general medicine clinic?
I hoped, Maybe it IS all a pannus. But the fluid wave. I couldn’t ignore a fluid wave. Her abdomen seemed to grow exponentially. It had to be ascites, but why? Her lungs were clear. A recent ECHO showed no evidence of heart failure. A set of liver function tests from last year was normal.
The last patient I took care of with ovarian cancer lived and died during my first internship, on my rotation in Gynecology-Oncology. I can still remember what her cries sounded like, and what her smile looked like. Her case infused my thoughts even when I was at home, though I tried not to let it. I knew it wasn't wrong to feel things while at work, but I didn't want to feel too much. I didn't want my emotions to hamper my job.
Seeing this new patient in front of me, this funny, pleasant, kind woman who brings her health to me and asks me to help take care of it, I know it is useless to hold back. If what happened to me with the previous patient repeats itself, then let it. If it hampers my job, it might also make me a better doctor.
Saturday, July 29, 2006
Formerly on ResidentDiary.com
I used to have a regular stint on ResidentDiary.com, but after eight months of random readers writing harsh, unprovoked comments and some writers' block on my part, I pulled the plug and set out on my own. So here I am. I can write about medicine or not. I can write in verse or not. The choices are endless! I continue to be a resident in Internal Medicine, but I am finally done with internship. I don't recommend two internships to anyone. And I wonder daily why I'm so tired and whether or not it's my thyroid. [It's not.]
I will be sure to post some poetry, even some plays, in the future, but for now, let's start with a short story. A vignette, if you will.
[[[]]]
I went to Catholic mass and heard my pastor preach about sin. He had his right hand in the air, I presume, pointing to God, and a large hardcover Bible cradled in the crook of his left arm. He looked quite holy and kind of scary, but strong. This is my pastor, I thought to myself. My pastor, whom I have seen naked twice.
He was in the military before he became a priest. I took care of him when he came in for chest pain at the local Veterans’ Affairs Medical Center. His voice sounded calm and deep, a quality in it deserving of reverence. I didn’t know whether to call him Father or Sir or Mr. He was half-dressed in a hospital gown and reading a novel by the window. He was a tall, thin man who thought he had a heart attack.
I perused his medical records. I asked him if he was taking his anti-retroviral medications daily. He said, Yes. My viral load has always been undetectable and my CD4 count above 350.
I nodded, penned his answers in my notes. I would schedule him for a stress test. His cardiac enzymes were negative, normal. He likely did not have a heart attack, but we wanted to be sure. I never asked him the one question everyone wanted to ask him but could and did not have a medically relevant reason to do so: How did you contract HIV?
Instead, I asked, How many sexual partners have you had in the last year?
I asked, Do you use protection? Every time?
I asked every question around the actual question. Perhaps I myself did not want to know. When I saw him again, months later, in church, he seemed to look through me. I don’t think he knew who I was. When I receive the holy host from his fingers each Sunday, I avert my eyes, and I have a feeling he knows who I am, but he chooses not to know.
I will be sure to post some poetry, even some plays, in the future, but for now, let's start with a short story. A vignette, if you will.
[[[]]]
I went to Catholic mass and heard my pastor preach about sin. He had his right hand in the air, I presume, pointing to God, and a large hardcover Bible cradled in the crook of his left arm. He looked quite holy and kind of scary, but strong. This is my pastor, I thought to myself. My pastor, whom I have seen naked twice.
He was in the military before he became a priest. I took care of him when he came in for chest pain at the local Veterans’ Affairs Medical Center. His voice sounded calm and deep, a quality in it deserving of reverence. I didn’t know whether to call him Father or Sir or Mr. He was half-dressed in a hospital gown and reading a novel by the window. He was a tall, thin man who thought he had a heart attack.
I perused his medical records. I asked him if he was taking his anti-retroviral medications daily. He said, Yes. My viral load has always been undetectable and my CD4 count above 350.
I nodded, penned his answers in my notes. I would schedule him for a stress test. His cardiac enzymes were negative, normal. He likely did not have a heart attack, but we wanted to be sure. I never asked him the one question everyone wanted to ask him but could and did not have a medically relevant reason to do so: How did you contract HIV?
Instead, I asked, How many sexual partners have you had in the last year?
I asked, Do you use protection? Every time?
I asked every question around the actual question. Perhaps I myself did not want to know. When I saw him again, months later, in church, he seemed to look through me. I don’t think he knew who I was. When I receive the holy host from his fingers each Sunday, I avert my eyes, and I have a feeling he knows who I am, but he chooses not to know.
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