tag:blogger.com,1999:blog-16588444130810321832024-03-13T04:08:46.203-05:00A Doctor, PracticingThe Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.comBlogger122125tag:blogger.com,1999:blog-1658844413081032183.post-8925769789782945122021-05-30T17:48:00.001-05:002021-05-30T17:48:16.086-05:00The patterns of the flesh<p>A wrongness beckons when I start walking-</p><p>what have I forgotten?</p><p>before, it was the opposite, fear striking</p><p>after I'd launched unassisted from a chair</p><p>the woman I was striding away as I faltered</p><p><br /></p><p>I learned too well from fear.</p><p>the woman I was clings with weak fingers</p><p><br /></p><p>can I move on again from myself?</p>The Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.com0tag:blogger.com,1999:blog-1658844413081032183.post-17194867034597538802021-05-04T19:35:00.001-05:002021-05-04T19:35:27.439-05:00Terrifying, Wonderful<p> It's been three weeks, and by the grace of God I can still walk.</p><span><a name='more'></a></span><p>Actually, I can almost run now. I can do jumping jacks, handstands, squats, pushups. I can dance a little salsa. I still can't stand on my toes, but the muscles in my feet are sore nearly every day and my walking is improving all the time, so I'm hopeful that I'll be able to stand on my tiptoes to reach the top shelf of my cabinets one day.</p><p>I cancelled my fancy powerchair. </p><p>You guys have no idea - <i>no idea</i> - how much work I had put in to try to get that chair ordered. It turns out getting the paperwork together to apply for a group 3 powerchair when your specialist works in another state requires essentially a part time job. I'm tenacious, though, so after about two months of spending hours each week on the phone with the insurance company, the assistive technology company, all three of my doctors' offices, and two different physical therapy practices, I had finally reached the last step before the claim could be submitted to my insurance: a joint evaluation with a physical therapist and an assistive technology professional. I was almost, <i>almost</i> done. Except the physical therapist wasn't available. Somehow the appointment wasn't on his calendar, even though it had been set up for weeks. We rescheduled for late March. Then we rescheduled again, for early April. Then we rescheduled <i>again, </i>this time for mid April - but before it could actually happen, there I was, hyperventilating over breakfast because I could walk. </p><p>It took a week to get a hold of one of my doctors. I really thought leaving daily messages with the nurses saying, "Hey! I can walk! It's a miracle! Also, what on earth do I do about this chair?" would get a quick response, but I forgot that clinic doctors are chronically overwhelmed and unlikely to respond to good news when they can barely put out all the fires. But I was desperate to share. Finally, my physiatrist called.</p><p>"You still need to get the chair," she told me matter-of-factly.</p><p>I took a breath and considered. That just didn't seem right. After all, this chair would be custom-made; it's not like I could just return it later. What if I never ended up needing it? What a colossal waste of resources that would be. Still, what about my own wasted resources - all the time and effort I'd sunk into getting this chair set up? I had no idea what the future might hold. What if I woke up one day completely unable to walk, and had to restart this six month process from the beginning because of my recklessness? </p><p>As my doctor expounded on the importance of having all the necessary tools available to me, I turned inward, and found a... knowing. A sense of faith, of trust. It would be okay. <i>I</i> would be okay. </p><p>When she paused for breath, I said, "I'm heel-toe walking now. All of a sudden. Without braces. I'm walking heel-toe." She had seen my awkward, mincing <a href="https://www.huffpost.com/entry/slap-gait-steppage-gait-and-foot-drop_b_5a3d1b04e4b06cd2bd03d9ff" target="_blank">steppage gait</a>, classic for my condition and known to be irreversible. She knew exactly what this meant.</p><p>There was silence like a stifled gasp on the line. Then she said, "Whoa." Then more silence.</p><p>"CMT doesn't do this," I said.</p><p>"CMT doesn't do this," she agreed.</p><p>We talked through all my testing, my symptoms, my improvement. She was deeply hesitant to leave me without a safety net if the worst happened, and who could blame her for that? Finally, we compromised; I would keep the travel powerchair I'd been contemplating returning, but I would not proceed with the custom chair.</p><p>Terrifying. Wonderful. Terrifying.</p><p>Just how all steps of faith are.</p><p>-----</p><p>I would like to say I'm dutifully doing my part in this, as far as strengthening my body and helping it achieve whatever it is we are doing here, but really I'm just reveling in being functional again. It's amazing how when you were facing severe disability, getting that ability back makes exercise a joy rather than a chore. I smile when sore muscles twinge. I whine about taking recovery days. I started drinking <i>protein shakes</i>. I plan on becoming an obnoxious athletic type if I possibly can.</p><p>Many people have asked if I'm going to return to clinical medicine, and to those people I say: calm down. I have no idea. I've barely even wrapped my mind around what's happening to me. I took the trash out today for the first time in at least a year. Let me get a few more of those out of the way. Ask me another day.</p><p>Today is still just for celebrating.</p>The Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.com0tag:blogger.com,1999:blog-1658844413081032183.post-19613307151120965852021-04-18T18:28:00.001-05:002021-04-20T12:36:01.416-05:00A Miracle from God<p>No one tells you this, but it turns out being supernaturally healed is pretty overwhelming. I suppose I might have expected that, but given that I wasn't expecting healing, I hadn't exactly done my research.</p><span><a name='more'></a></span><p>Here's what I know about what happened.</p><p>Thursday and Friday, my husband and I celebrated our vaccinated status as well as his retirement from the military by taking an overnight trip out of town. It was lovely, although impeded by my difficulty walking or using my hands. I walked short distances, slowly, using my leg braces and a crutch. I couldn't use chopsticks at dinner due to my impaired fine motor control so I had to request a fork. I woke up once overnight to use the restroom and had to use the wall for balance and be careful that my legs didn't buckle underneath me.</p><p>Saturday we visited some dear (vaccinated) friends at their house for dinner. It was about a two hour drive from our home. Dinner was lovely, though impeded by my difficulty walking or using my hands. I limped around, slowly and for short distances only, with a crutch, after taking my leg braces off. My husband had to cut my meat for me. I had trouble keeping a grip on my wineglass. </p><p>We drove home uneventfully.</p><p>As we were getting the house tidied up for the night before bed, I remarked to my husband that my legs felt a bit funny. I walked on them for a couple of steps, then - with astonishment - walked across the kitchen with just my braces, no crutch. My husband and I were both floored by this, but it was also midnight, and the idea that I might have a change in my function was too much to handle. We decided not to discuss it and went immediately to bed. As I lay there, my pillow soft under my cheek, I thought to myself, <i>I wonder what is going</i>-</p><p>I woke up the next morning in the middle of my sentence<i>,</i> in full mental flow but only gradually becoming aware that time had passed - <i>on, why my legs would feel so different all of a sudden, I wonder if something has really changed</i>. I noticed I was awake, and realized I must have slept. My husband was already up, the bed cool next to me.</p><p>I sat up.</p><p>Pushed off the covers.</p><p>Stood.</p><p><i>And strode across the room</i>.</p><p>Strode. <i>Strode</i>, as in, walked quickly, using both legs equally. Strode. Across the room. By myself - no braces, no crutch, no cruising the furniture like a toddler. Just me and my two legs, walking as though walking were something we accomplished every day.</p><p>There's a blank spot in my memory after that.</p><p>My husband tells me I yelled for him, then walked <i>like a normal walking person </i>into the living room. I believe him, but I don't remember that. The next thing I remember is becoming hysterical as I tried to eat a piece of toast. I think a person is allowed some hysteria when they suddenly, and in defiance of everything known about their disease process, wake up one morning and find <i>they have</i> <i>literally regained the ability to walk</i>. </p><p>-----------</p><p>The week since has been very interesting indeed, and by, "very interesting" I mean, "totally overwhelming and astonishing." I woke up the day after my miraculous recovery feeling sore everywhere, even the muscles in my hands and feet - which, considering I don't really <i>have</i> muscles there anymore (they atrophy and disappear after a point), leaves me simply marveling. And I've continued to improve by a huge margin each day. My arms and legs have gotten stronger. My shortness of breath and daily fatigue have utterly vanished. Here is a nonexhaustive list of the things I've done this week that I haven't been able to do for anywhere from six months to several years: yell, type quickly, jump, walk without braces (walk without braces!), do squats, hold a mug with one hand, use a knife at dinner, work a zipper with one hand, wiggle my toes. Oh, and dance. There has been much dancing.</p><p>I think God did this, and not through natural mechanisms. There is no known natural mechanism for this. I think the God of the Bible did... something... and directly caused healing in my body, for reasons that are His alone and for purposes I don't yet understand. I don't understand any of this, actually. But I know that God is powerful and good, that Jesus loves me (and you!), and that He deserves trust and worship. And that I can walk.</p><p>I do think it's important to say that my function still isn't normal<i>. </i>I still have some weakness and cramping in my right wrist and both feet, and some numbness remains. I have no idea if I'll continue to improve like I have been or if this is as far as it will go.</p><p>But that means at worst, God has put me back where I was three full years ago, almost before I knew I had anything wrong at all.</p><p>-----------</p><p>I think some fairly specific, technical background information is extremely important here, and I think it's necessary to put it in this post so anyone reading this has everything in one place.</p><p>The most important thing to address is that I was not misdiagnosed, nor was my diagnosis ever in question. <a href="https://doctorpractice.blogspot.com/2018/08/news.html">When I was diagnosed</a> with <a href="https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Charcot-Marie-Tooth-Disease-Fact-Sheet" target="_blank">Charcot-Marie-Tooth disease</a>, I received a clinical diagnosis from a general neurologist first, followed by a nerve conduction study and EMG which was performed and interpreted by a neuromuscular neurologist. I also had genetic testing. All stages of my evaluation were confirmatory for CMT 1a. What this means is that two neurologists, one of whom specializes in neuromuscular diseases like mine, found that I had a diagnosis of CMT, and that this was further confirmed and subtyped as 1a via a genetic test. The nerve conduction study/ EMG also ruled out several alternate possible diagnoses, most notably Guillain-Barre and CIDP (not that my presentation was convincing for either of these for a number of reasons). My acetylcholinesterase antibodies were negative, which makes myasthenia gravis very unlikely. And I had an MRI of my brain and cervical spine which was normal; that along with the EMG ruled out multiple sclerosis. Again, clinically my symptoms were entirely consistent with CMT from the very beginning, and very inconsistent with anything else. </p><p>The takeaway from all of this is that there is essentially no diagnostic uncertainty about what I have. I have CMT 1a. And this really matters, because we know CMT 1a does not suddenly improve. With persistent exercise, there can be modest, hard-earned improvement; otherwise it worsens slowly over time with periods of more rapid progression. This had been my experience up until the past week.</p><p>I also think it helps to get a good idea of just how much improvement I'm talking about here. This is not just a few good days. As of a week ago, I could only walk about half normal walking speed, and I required leg braces and a crutch to do so. Weakness and patchy numbness had progressed from my feet up into my thighs and, on my right side, my hip, causing muscle cramps and burning as well as instability. My toes, feet, and ankles were mostly paralyzed. My forearms and wrists were too weak to open a bottle of medication, pull a zipper, or write more than a couple of words. I was fatigued, a horrible exhausted sensation, all the time. And I was recently diagnosed with mild to moderate neuromuscular respiratory weakness after having formal pulmonary function testing done. I'm currently in the process of applying for a power wheelchair due to the severity of my condition.</p><p>I'm trying to decide how to tell them I don't need that anymore, considering I haven't needed any assistive devices since this healing began.</p><p>-----------</p><p>If I told you that you should be grateful - thankful to God - for your ability to breathe, or your ability to walk, and it were something you had always been able to do, I think you would intellectually be able to understand what I was saying. Walking, breathing, using your hands; they're all great things. But you wouldn't <i>feel</i> the gratitude, feel it at a deep emotional level. </p><p>I really feel that gratitude now. </p><p>Every time I can type something at normal speed without pain, or fold a towel, or write. Every time I walk across a room without any assistive devices. Every time I stretch without all my muscles locking up in protest. Every time I raise my voice without feeling short of breath. Every time this week that I have been able to do one of a hundred tiny things that I used to take for granted as an able-bodied person but that have eluded me more and more over the past five years, I have felt a rush of humble thankfulness so powerful it borders on panic. It is truly experiencing the fear of the Lord.</p><p>And yet... I can't help but remember something I heard Joni Eareckson Tada say several years ago: <a href="https://doctorpractice.blogspot.com/2018/09/suffering.html" target="_blank">there are better things than walking.</a> That is true. It was true when I could walk before, and it was true when I had almost lost my walking, and now that I can walk again <i>it is still true</i>. And listen, I don't know where this is going. It's not like there's a user manual for miracles. Is this temporary? Is it permanent? Will my condition improve from here, worsen, what? And don't even get me started on the potential implications; I can barely think about those at this point. I just know that although this gift is powerfully good, Jesus is better. And I will still count Him as better than any physical function even if I lose my ability to walk again, even if He takes it away tomorrow or next week. </p><p>But while it's here, I plan to enjoy it to its fullest. </p>The Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.com3tag:blogger.com,1999:blog-1658844413081032183.post-84846022610290238442021-02-14T08:47:00.001-06:002021-02-14T08:47:58.152-06:00February 2021, or, Functionally Speaking<p>I bought a wheelchair yesterday.<span></span></p><a name='more'></a><p></p>There's <a href="https://www.irishtimes.com/culture/books/paraic-o-donnell-ms-is-meticulously-destroying-me-i-am-being-unmade-1.4168380" target="_blank">a piece</a> I read a while back about how disability unmakes you. Its cold hopelessness, its angry isolation, is something I carry in the dark places where like calls to like. The author walks us through how the loss of his body is the loss of his self in a way, something I am also living, because I am losing my body too, and we are dual-natured creatures, the eternal married to the animal. <div><span><br /></span></div><div>I'm so sick of constantly feeling like I am a hairsbreadth from falling over.</div><div><span><br /></span></div><div>So I bought a wheelchair. An electric wheelchair. It's a measure for backups and travel, and also a stopgap; I am simultaneously beginning the much longer process of being fitted for a custom powerchair, but that takes three to six months (<i>three to six months?!</i> I hear you say in disbelief. Yes. Three to six months) and those chairs are comfortable but enormous. This is a lighter, off the shelf version that is still powered, so it's meant to be more portable and convenient (convenient = you don't need to literally buy an entire vehicle to schlep it around), and you would be shocked at how difficult it is to find one that isn't totally hideous. </div><div><br /></div><div>I'm generally a pretty practical person, but this has been a sticking point for me during the research process. Why are they all so terrible looking? Is it not enough just to need one? Must I also use something <a href="https://www.pridemobility.com/jazzy-power-chairs/jazzy-passport/" target="_blank">obnoxiously branded</a> or <a href="https://www.forcemech.com/voyager_r2/" target="_blank">bright yellow</a> or that looks like <a href="https://www.drivemedical.com/us/en/products/mobility/power-wheelchairs/portable-folding-power-wheelchairs/cirrus-plus-ec/p/558-1" target="_blank">it's from a 1995 hospital TV drama</a>? Hear me out, here. When is the last time <i>you </i>wanted to be out and about in something you thought was ugly and not at all your style? Or something that didn't match your clothing choices but was nevertheless the most visible part of you? </div><div><br /><div>Before, I used to have some control over how I looked to people. I could stand out. I could blend in. I could go to dinner with my husband in a skintight acid-green leopard print onesie (that is a lie. He would never go to dinner with me if I had that on). But now, even if I wore the onesie, the first thing anyone would see would still be the <i>chair</i> and <i>I don't even get to decide what it looks like</i>.</div><div><span><br /></span></div><div>And I know, I know, the chair is a marvel of modern engineering. It's an incredible blessing that I can even afford one, let alone that I also have the health insurance to eventually have two. Most disabled people in this world don't have the luxury of <i>options</i>. Not everything is about aesthetics (lol I have literally walked through the hallways of my workplace many times with other people's bodily fluids on me so the fact that I torture myself with this particular line is hilarious). But just like joy and grief can be bedfellows, I can hold my gratitude and my deep, bleak resentment in the same hand. The ratio changes from day to day. I'm hoping when this thing arrives, my innate stubborn practicality will rear its head, and I can leave the resentment behind. </div></div><div><br /></div><div>The loss remains, though. When you are healthy, you don't think about how essential expression of your eternal self takes place through this physical vessel you inhabit; you use your body to do the things that matter to you. Your body carries you through this world and it's the avenue by which you experience and interact with everything. And it's also how the world interacts with you. </div><div><br /></div><div>So yes, the chair is emblematic of a hideous loss of self. Because while I remain a Christian, a doctor, someone who loves beauty, someone who hates injustice, a committed wife-friend-sister-daughter-person, the ways I can actually <i>express</i> those things are dwindling, and no one teaches you how to process the grief of such dislocation. I'm the same person but I can't do any of the things that used to let me feel like I was living authentically. So... functionally speaking... who am I now?</div><div><br /></div><div>How do I even figure that out?</div>The Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.com2tag:blogger.com,1999:blog-1658844413081032183.post-85951824462545565462020-12-31T21:55:00.005-06:002020-12-31T21:55:49.193-06:00So Here's To Hope<p>I'm pretty sure I cried straight through the first half of 2020.</p><p>In my defense, I was having an objectively tragic year. I left not just my job but my career under the unrelenting pressure of my worsening disability. My husband and I moved, again, this time for a job I knew I needed but wasn't sure I wanted. Two close family members developed devastating chronic illnesses. And I realized that I'm gradually losing my ability to walk and use my hands. All this against the backdrop of, y'know, the raging collective trash fire that has been 2020.</p><p>All I was was sad, all the time. I couldn't even talk to anyone about it, really. I just cried every day.</p><p>Midway through the year, a close friend sent me a link to a book and informed me we were going to read it together.</p><p>I clicked on the link and was greeted by a bright yellow cover with - of all things - an enormous smiley face on it. <i>The Happiness Advantage</i>, the cover screamed. <i>How a Positive Brain Fuels Success in Work and Life.</i> I snorted and texted her back some version of <i>absolutely not</i>. I wasn't about to buy a <i>yellow smiley book</i> on <i>being happy</i>. I don't like yellow. Or being told how to feel. I'm not even sure I like happiness. I find it suspicious a lot of the time, schmaltzy and commoditized, and often exhausting. A forced smile in a toothpaste ad. No. </p><p>When it arrived a mere two days after I ordered it, the book and I stared at each other for a bit. <i>I can't believe I'm reading this stupid book</i>, I texted my friend. <i>Don't ever doubt my love for you.</i> She responded in the cheerfully assumptive manner of someone who never has: <i>we should discuss once a week. Do you want to do one chapter at a time or two?</i></p><p>I truly didn't expect this book to change me so much.</p><p>The breakthrough came when we got to the chapter about gratitude. Gratitude: another word I have learned to eye suspiciously, given its cachet with trendy influencers and people who like motivational posters. It conjures up carefully posed social media posts full of product placements - cynicism lacquered in toxic positivity. This was different, though. The author gave a simple hypothesis: maybe the brain can be trained to be more optimistic by marking the good things that are already present in one's life. Invoking the power of accountability, he suggested telling a close friend or loved one three things you are grateful for each day, things that didn't have to be profound but did need to be specific. This appealed to me. It seemed practical and attainable. Maybe we could try it?</p><p>So we began. Every day, we would tell each other about a great cup of coffee or a glimpse of beauty, a moment of laughter, a kindness we received. For the most part we kept it small. Almost immediately, we realised that just hearing about the other's happy moments brightened our own day. We didn't anticipate this recursive loop of happiness, but we embraced it, and it became its own self-reinforcing system. We would reach out to each other greedily in the evenings, sometimes simultaneously: <i>tell me about your day! What are you grateful for?</i></p><p>Some days it was a real stretch. It's 2020; a lot of crummy things happened. And nothing about this exercise changed the essential facts of my life. But with practice, we learned that even on the worst days, there was something to feel legitimately grateful for.</p><p>This may sound basic, but consider its effects. In the manner of a river slowly changing its bed, my focus has gradually eroded away from the major obstacles I face, instead eddying around bits of happiness. I'm learning to better appreciate small pleasures. And I'm finding that I'm emotionally stronger for it. Far from this change being a distraction or a waste of time, when I turn back to the big challenges they are somehow less overwhelming, because I recognize now that my life will always have a wealth of good things in it. I just have to take the time to notice them.</p><p>It's my prayer that in 2021, we would all be able to apply this lesson. There is joy trickling through all the little cracks in our lives, and this next year I hope to settle into that understanding further. It's a small goal, but I'm satisfied with that. A change, no matter how incremental, can gather a curious momentum of its own with time, gradually pressing through the mud to find hope.</p><p>So here's to hope.</p><p>Happy New Year.</p>The Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.com6tag:blogger.com,1999:blog-1658844413081032183.post-63796095379105433122020-05-04T11:15:00.000-05:002020-05-04T18:04:22.677-05:00Song of Ascents<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;">"Are you ready to leave clinical medicine?"</span><br />
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<span style="font-family: inherit;">His indifferent tone belied the importance of the question, not just to me but to the eight other people currently sitting around the table, waiting for my response with varying degrees of patience and interest. Outside, an unseasonably warm January day coaxed buds from the trees dotting the hospital campus.</span></span><br />
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<span style="font-family: inherit;">I looked over at the chief medical officer of the hospital and blew out a wry breath. A half truth slipped out before I could stop it. "Is anyone really ready to leave clinical medicine?"</span></span><br />
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<a name='more'></a><span style="font-family: inherit;"><span style="font-family: inherit;">He raised his eyebrows at me, unimpressed, and I gave myself a mental shake. <i>Zoe, you planned this one</i>, I chided myself. <i>Follow the script.</i> My interviewers didn't need to know everything - anything, really - about me. They just needed reassurance I wouldn't try to stick my nose into issues outside my job description.</span></span><br />
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<span style="font-family: inherit;">Issues like patient care.</span></span><br />
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<span style="font-family: inherit;">I glanced down at my hands, hoping they would take my short pause as merely evidence I was preparing a good response. Then I pasted a confident expression on my face.</span></span><br />
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<span style="font-family: inherit;">"I won't sugarcoat that I love my patients and I love taking care of them. But I'm also excited to transition to what I view as a different way to care for patients..."</span></span><br />
<span style="font-family: inherit;"><span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">Blah, blah, blah. They seemed satisfied.</span></span><br />
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<span style="background-color: white; color: #222222; font-family: inherit;">Of course I'm not ready to leave clinical medicine. I'm less than five years out from my training and I only just </span><a href="https://doctorpractice.blogspot.com/2018/04/change.html" style="background-color: white; font-family: inherit;" target="_blank">reclaimed my love for patient care</a><span style="background-color: white; color: #222222; font-family: inherit;"> after having it </span><a href="https://doctorpractice.blogspot.com/2016/08/the-other-side-of-disillusionment.html" style="background-color: white; font-family: inherit;" target="_blank">stripped from me</a><span style="background-color: white; color: #222222; font-family: inherit;"> during residency. How am I meant to leave all that I have here? The team that I have lived life with, who saw me </span><a href="https://doctorpractice.blogspot.com/2018/05/on-terror.html" style="background-color: white; font-family: inherit;" target="_blank">come into my own</a><span style="background-color: white; color: #222222; font-family: inherit;"> as an attending - who helped me navigate the new reality of my career-ending diagnosis? The patients who I laughed and cried (and argued) with? I'm not even a little bit ready to give up the </span><a href="https://www.kevinmd.com/blog/2019/12/the-difference-between-shallow-and-deep-work-in-medicine.html" style="background-color: white; font-family: inherit;" target="_blank">intense controlled chaos</a><span style="background-color: white; color: #222222; font-family: inherit;"> that was my ER job. Even on the days I hated it, I loved it. </span><br />
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<span style="font-family: inherit;">But I can't suture anymore. I can't open a package of gauze, or reduce a difficult joint, or any number of things that require physical strength, manual dexterity, <a href="https://doctorpractice.blogspot.com/2018/08/spoons.html" target="_blank">or both</a>. And I'm worn out. </span><span style="background-color: transparent;">In my ER, I was working twelve (read: thirteen or fourteen) hour days, constantly on my feet, often without a break. That used to be exhilarating; over the past couple of years it became simply exhausting. For every shift I worked, it would take anywhere from a couple of days to a week to recover my strength. </span></div>
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<span style="font-family: inherit;">So I spent the past year quietly, reluctantly looking for a desk job. I picked up a side gig reviewing medical claims for insurance companies and quickly realised that the only time I liked the work was when I could get coverage approved. It paid more in experience than dollars, but I can't be mad at that, because that experience is what got me to that hospital interview, pretending I wanted to be there.</span></div>
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<span style="font-family: inherit;">When they called a couple months later to offer me the job, I was at work in the ER, because of course I was. Actually, I was juggling two other phone calls and an ambulance was arriving when my cell phone rang. There was no chance I could actually pick up. In a moment of mild hysteria I thought, if they don't give me the job because I didn't answer on the first ring, so be it. </span></div>
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<span style="font-family: inherit;"><br /></span></div>
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<span style="font-family: inherit;">Later, I finally called them back. </span></div>
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<span style="font-family: inherit;">"Are you so excited?!" Apparently they were very excited. I closed my eyes, shoved a swell of grief to the side, and chirped, "I am! Thrilled! Looking forward to it!"</span></div>
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<span style="font-family: inherit;">The title of my new position is physician advisor. My role will be somewhere between administrator and consultant, and it sounds like it will involve wearing several hats. I'll deal with insurance companies on behalf of the hospital, help with billing/ coding issues, and hopefully get to do a little education. Honestly, it's a good job, and one where I will be able to take some of the load off doctors while still directly impacting patients in some way. Once I give it a proper chance, I'm sure I'll like it.</span></div>
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<span style="font-family: inherit;">I keep telling myself that, anyway. One day maybe I'll even be convinced. But I know it's not really about what I'm heading into; the problem is all that I'm leaving behind.</span></div>
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<span style="font-family: inherit;">In the Old Testament of the Bible, nestled in the middle of the psalms, is a series called the Songs of Ascent. They were songs for the ancient Israelites to sing as they made their pilgrimage up the mountains to the temple in Jerusalem. You would think a series meant for holy pilgrimage would be purely triumphant, but it is not. Instead, the songs are beautifully complex. They speak of fear and hardship, and then comfort with reminders of God's love. Sometimes they grieve. Sometimes they ask for mercy. Make no mistake, God's people suffered. They suffered, and they grieved, and they trusted God, and they worshipped Him. And ultimately, the songs rejoice, sharing the wonderful things God has done for His people and trusting that He will continue to care for them.</span></div>
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<span style="font-family: inherit;">These songs have become my close companion; it's comforting to know I'm not the first. Others have lost things and made it through, singing. It gives me hope. I have hope that there are more good things to come, and that God will give me continued meaningful work even though I won't be seeing patients anymore. I have hope that I will have a place again one day where I can have a team I love, where I can belong and contribute. I have hope, above all, that this is a journey that the Lord has blessed. So as I grieve and rejoice, as I remember the incredible things God has done in my life, as I fight my fear of the future,</span></div>
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<span style="font-family: inherit;"><span class="text Ps-130-5" id="en-NIV-16146" style="box-sizing: border-box; color: black; position: relative;">I wait for the Lord,<span class="crossreference" data-cr="#cen-NIV-16146I" data-link="(<a href="#cen-NIV-16146I" title="See cross-reference I">I</a>)" style="box-sizing: border-box; line-height: 22px; position: relative; top: 0px; vertical-align: top;"></span> my whole being waits,<span class="crossreference" data-cr="#cen-NIV-16146J" data-link="(<a href="#cen-NIV-16146J" title="See cross-reference J">J</a>)" style="box-sizing: border-box; line-height: 22px; position: relative; top: 0px; vertical-align: top;"></span></span><br style="box-sizing: border-box; color: black;" /><span class="indent-1" style="box-sizing: border-box; color: black;"><span class="indent-1-breaks" style="-webkit-font-smoothing: antialiased; box-sizing: border-box; line-height: 0;"> </span><span class="text Ps-130-5" style="-webkit-font-smoothing: antialiased; box-sizing: border-box; position: relative;">and in his word<span class="crossreference" data-cr="#cen-NIV-16146K" data-link="(<a href="#cen-NIV-16146K" title="See cross-reference K">K</a>)" style="box-sizing: border-box; line-height: 22px; position: relative; top: 0px; vertical-align: top;"></span> I put my hope.<span style="font-weight: bold;"> </span></span></span></span><br />
<span style="font-family: inherit;"><span class="text Ps-130-6" id="en-NIV-16147" style="box-sizing: border-box; color: black; position: relative;">I wait for the Lord</span><br style="box-sizing: border-box; color: black;" /><span class="indent-1" style="box-sizing: border-box; color: black;"><span class="indent-1-breaks" style="-webkit-font-smoothing: antialiased; box-sizing: border-box; line-height: 0;"> </span><span class="text Ps-130-6" style="-webkit-font-smoothing: antialiased; box-sizing: border-box; position: relative;">more than watchmen<span class="crossreference" data-cr="#cen-NIV-16147L" data-link="(<a href="#cen-NIV-16147L" title="See cross-reference L">L</a>)" style="box-sizing: border-box; line-height: 22px; position: relative; top: 0px; vertical-align: top;"></span> wait for the morning,</span></span><br style="box-sizing: border-box; color: black;" /><span class="indent-1" style="box-sizing: border-box; color: black;"><span class="indent-1-breaks" style="-webkit-font-smoothing: antialiased; box-sizing: border-box; line-height: 0;"> </span><span class="text Ps-130-6" style="-webkit-font-smoothing: antialiased; box-sizing: border-box; position: relative;">more than watchmen wait for the morning.</span></span></span></div>
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The Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.com2tag:blogger.com,1999:blog-1658844413081032183.post-64221483057089143252020-03-19T14:34:00.002-05:002020-03-21T21:11:18.313-05:00Covid-19: Yes, you need to stay home.<div style="background-color: white; color: #222222;">
<span style="font-family: inherit;">I don't know about you guys, but I've been hearing a lot of grumbling lately about how the response to the covid-19 pandemic is "overblown." That's the word they've been using. There seems to be a collective sense that covid-19 is not very serious and because of that, the public health response is an overreaction. We should just live our normal lives, let this little cold run its course, and move on.</span></div>
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<span style="font-family: inherit;">Please do not fall prey to this misunderstanding.</span></div>
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This infection couldn't be less routine. So why are people wanting business as usual? My hypothesis and hope is that for most people, the important information just hasn't been presented in a way they can easily digest. Give people the information they need in a way that makes sense, and maybe they will make better decisions. This post is the beginning of my contribution to that effort.</div>
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<br /></div>
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<span style="font-family: inherit;">The flu is a convenient point of comparison since right now it feels like the devil we know. In the United States, flu picks up around October and dies back beginning in March. You get it primarily from other people sneezing/ coughing around you, or from touching surfaces with virus on them and then touching your face. There's a lag time of 1-4 days between exposure and getting sick, and each infected person infects another 1-2 people. We all know the symptoms: body aches, fever, runny nose, cough, lasting 5-10 days. Pneumonia is uncommon. The vast majority of people with the flu feel crummy but are in no danger - only about 1-2% of people with the flu get admitted to the hospital. And about 0.1% of people with the flu die from it, or 1 in 1000.</span></div>
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<span style="font-family: inherit;"><br /></span></div>
<div style="background-color: white; color: #222222;">
<span style="font-family: inherit;">So the flu isn't <i>that</i> contagious, and it's not <i>that</i> deadly. Despite that, when the flu is finally done with our country each spring, healthcare workers are exhausted from the extra workload and tens of thousands are dead. In the 2018-2019 flu season, we saw nearly half a million hospitalizations and 34,000 deaths.</span></div>
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<span style="font-family: inherit;">Let's contrast that with what we have so far on covid-19.</span></div>
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<span style="font-family: inherit;">Covid-19 is also a virus and it is spread in roughly the same way as the flu. Mild cases look similar. But there the similarities end. For starters, the lag time between exposure and illness can be up to two weeks. For people who get sick, the symptoms last anywhere from 7 days to a month, and pneumonia, or lung infection, is much more common. Early data shows that covid-19 is 2-3x more contagious than the flu, and strongly suggests it is also 10-40x more deadly. It is also about 10x more severe - somewhere between 10% and 20% of people who get sick end up in the hospital (references at the end; I recognise that these numbers are dynamic, but these are the current best estimates). </span><br />
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">That's one out of every ten people who get sick, maybe as high as one out of every <i>five</i>. Very different than one out of 100.</span></div>
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<span style="font-family: inherit;">A lot of people focus on the case fatality rate, or how many people who get covid-19 will die from it. But I think time will show that this is the less important statistic when it comes to making decisions. Much more important for all of us is the high hospitalization rate, which appears to hold <i>for adults of all ages</i>. A large proportion of people need hospital support to make it through this illness. And the resources for that support </span>- oxygen, IV fluids, respiratory support, not to mention beds to sleep in and staff to give the actual care<span style="font-family: inherit;"> - are finite.</span></div>
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<span style="font-family: inherit;"><br /></span></div>
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<span style="font-family: inherit;">Do you want access to hospital care if you get seriously ill? I do.</span></div>
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The high infectiousness and moderate severity of covid-19 combine to threaten our communities with a huge health burden. <span style="font-family: inherit;">If the spread of this infection is not controlled, our clinics and hospitals will be overwhelmed by a massive influx of severe illness. The result will be healthcare spread thinly and ragged at the edges. </span><span style="font-family: inherit;"> </span><a data-saferedirecturl="https://www.google.com/url?q=https://www.nytimes.com/2020/03/12/upshot/coronavirus-biggest-worry-hospital-capacity.html&source=gmail&ust=1584673404932000&usg=AFQjCNFBZEmEag6u2fw8sO-P6zhPMbKMhw" href="https://www.nytimes.com/2020/03/12/upshot/coronavirus-biggest-worry-hospital-capacity.html" style="color: #1155cc; font-family: inherit;" target="_blank">An article in the New York Times</a><span style="font-family: inherit;"> </span><span style="font-family: inherit;">gives a helpful and accurate summary of the situation (article dated March 12th; their cases have tripled since the article was written). Here's a brief excerpt in case you can't see the article:</span></div>
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<div style="background-color: white; color: #222222;">
<span style="font-family: inherit;">"The cautionary tale is Italy. More than 12,000 people have been infected there; more than 800 have died. A little over 1,000 have recovered. Many of the rest are ill. And a significant number of them need to be hospitalized — right now.<br /><br />"This has exceeded Italy’s capacity for care. It doesn’t matter what physicians’ specialties are — they’re treating coronavirus. As health care providers fall ill, Italy is having trouble replacing them. Elective procedures have been canceled. People who need care for other reasons are having trouble finding space."</span></div>
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The takeaway here should be that even though many people have a low individual risk, <i>everyone</i> has a huge societal risk. <span style="font-family: inherit;">I want to highlight that resource management is a major concern here, and should be a motivator for all of us. </span>This is not something Americans have really had to be aware of before. <span style="font-family: inherit;">You want to try not to get this infection if possible, but you also want to slow the community spread as much as possible, so that if you do get sick, and you need healthcare, that care is actually available when needed. </span></div>
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<span style="font-family: inherit;">I hope that explains why social distancing on a widespread level is necessary.</span></div>
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<span style="font-family: inherit;"><br /></span></div>
<div style="background-color: white; color: #222222;">
<span style="font-family: inherit;">So yes, please, wash your hands often and stay home when you're sick. But also avoid public places, even if you're not under a local mandate to do so. Expect these precautions to be in place for several months, likely through the spring and possibly into summer, although no one can be certain at this point. </span></div>
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<span style="font-family: inherit;"><br /></span></div>
<div style="background-color: white; color: #222222;">
<span style="font-family: inherit;">We each have an important role to play in our communities in protecting ourselves and each other.</span></div>
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<span style="font-family: inherit;"><br /></span></div>
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<span style="font-family: inherit;">In the next week I'll post about what it means to be "high-risk" and what additional implications that carries. And let me know if there are any specific questions you have about this infection.</span></div>
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<span style="font-family: inherit;">-------------</span></div>
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<span style="background-color: white; font-family: inherit;"><i>References for flu severity:</i></span></div>
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<span style="background-color: white; font-family: inherit;">Reed C, Chaves SS, Kirley PD, Emerson R, Aragon D, Hancock EB, Butler L, Baumbach J, Hollick G, Bennett NM, Laidler MR. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4349859/" target="_blank">Estimating influenza disease burden from population-based surveillance data in the United States.</a> PloS one. 2015;10(3). </span></div>
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<span style="background-color: white; font-family: inherit;"><br /></span></div>
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<span style="background-color: white; font-family: inherit;"> Matias G, Taylor R, Haguinet F, Schuck‐Paim C, Lustig R, Shinde V. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4181813/" target="_blank">Estimates of mortality attributable to influenza and RSV in the United States during 1997–2009 by influenza type or subtype, age, cause of death, and risk status.</a> Influenza and other respiratory viruses. 2014 Sep;8(5):507-15.</span></div>
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<span style="background-color: white; font-family: inherit;"><a href="https://www.cdc.gov/flu/about/burden/2018-2019.html" target="_blank">CDC report on influenza disease burden for the 2018-2019 season.</a></span></div>
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<span style="background-color: white; font-family: inherit;"><br /></span></div>
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<span style="background-color: white; font-family: inherit;"><i>References for COVID-19 severity:</i></span></div>
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<span style="background-color: white; font-family: inherit;"><i><br /></i></span></div>
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<span style="background-color: white;"><a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e2.htm?s_cid=mm6912e2_w" target="_blank">CDC weekly update on covid-19, dated 18 March.</a> Important because this is our first look at statistics from America.</span><br />
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<span style="background-color: white; font-family: inherit;"><span style="background-color: #f8f8f8;">Lauer SA, Grantz KH, Bi Q, Jones FK, Zheng Q, Meredith HR, Azman AS, Reich NG, Lessler J. <a href="https://annals.org/aim/fullarticle/2762808/incubation-period-coronavirus-disease-2019-covid-19-from-publicly-reported" target="_blank">The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application.</a> Annals of Internal Medicine. 2020 Mar 10.</span></span></div>
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<span style="background-color: white; font-family: inherit;"><i><br /></i></span></div>
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<span style="background-color: white; font-family: inherit;">Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, Liu L, Shan H, Lei CL, Hui DS, Du B. <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2002032" target="_blank">Clinical characteristics of coronavirus disease 2019 in China.</a> New England Journal of Medicine. 2020 Feb 28. </span></div>
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<span style="background-color: white; font-family: inherit;"><br /></span></div>
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<span style="background-color: white; font-family: inherit;">Xu Z, Li S, Tian S, Li H, Kong LQ. <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30308-1/fulltext" target="_blank">Full spectrum of COVID-19 severity still being depicted.</a> The Lancet. 2020 Feb 14.</span></div>
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<a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30627-9/fulltext" target="_blank">Lancet article on the current situation in Italy.</a> It's a good summary of that country's demographics, infectiousness, severity, and public health considerations.</div>
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The Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.com0tag:blogger.com,1999:blog-1658844413081032183.post-76353031173018224472019-12-13T16:16:00.000-06:002019-12-14T21:43:57.895-06:00Like airI fought for her as she held<br />
her diamond breath in her<br />
hands, close<br />
close to her chest<br />
finite and precious<br />
saving it carefully, losing it<br />
every other word<br />
<br />
When I returned<br />
heavy-laden from long hours<br />
she smiled<br />
took my hand and prayed<br />
and I felt<br />
the breath I had given her<br />
being returnedThe Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.com0tag:blogger.com,1999:blog-1658844413081032183.post-41508531358716637692019-09-21T22:35:00.000-05:002019-09-21T22:35:22.183-05:00Healing<span style="font-family: inherit;">"Your kidneys have shut down.</span><br />
<span style="font-family: inherit;">There's nothing I can do.</span><br />
<span style="font-family: inherit;">I'm so sorry."</span><br />
<span style="font-family: inherit;">Her husband held her as she cried.</span><br />
<span style="font-family: inherit;">Later, I came back.</span><br />
<span style="font-family: inherit;">We talked of the power</span><br />
<span style="font-family: inherit;">of The Great Physician.</span><br />
<span style="font-family: inherit;">I prayed for her.</span><br />
<span style="font-family: inherit;">She clutched my hands in thanks</span><br />
<span style="font-family: inherit;">And I realized</span><br />
<span style="font-family: inherit;">That in my helplessness</span><br />
<br />
<span style="font-family: inherit;">I had offered true medicine.</span>The Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.com0tag:blogger.com,1999:blog-1658844413081032183.post-64548203860036241112019-08-14T20:42:00.000-05:002019-08-14T20:42:00.488-05:0055 wordsI fell down a little narrative medicine hole today, and in so doing, I found a writing mechanism called the 55-word story. There is an excellent discussion of this mechanism in this <a href="https://journalofethics.ama-assn.org/article/doctors-stories-doctors-stories-and-back-again/2017-03" target="_blank">JAMA article from 2017</a>. Writing is a tool for processing, reflection, entertainment, teaching, and so much more. But sometimes you just <i>don't have any bloody time</i>. Enter this tiny sliver of writing! It's almost a game - 55 words exactly, no more, no less, but in any format you'd like - and completing one is terribly satisfying.<br />
<br />
I am going to start doing this, and I hope it will be a regular event. Here is today's story.<br />
<br />
<br />
<a name='more'></a><br />
<i><u>PALS</u></i><br />
<br />
You'd think they would be blase about it<br />
but instead, they take notes, intent<br />
in a class they have taken before<br />
<br />
They know<br />
the particular fear<br />
of holding a mother upright as she says goodbye<br />
and they know they must answer, to her, to themselves, to the fear<br />
<i>We did our best. We did everything</i>.The Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.com0tag:blogger.com,1999:blog-1658844413081032183.post-5768651001869692992019-08-09T05:51:00.002-05:002019-08-09T05:51:42.123-05:00PerspectiveMy boss leaned back and put her hands on her hips. "Well, you know what? I think we kicked ass today. Well done."<br />
<br />
I didn't lift my eyes from the transfer paperwork I was filling out at top speed. "Do you think so? I just feel like I got my ass handed to me all day."<br />
<br />
She was unfazed. I saw her shrug out of the corner of my eye. "No, I think we did a good job. It was tough today but we took care of patients."<br />
<br />
I grunted. "I guess."<br />
<br />
--------<br />
<br />
Her words came back to me several hours later, when I was driving home berating myself. It's something I do often. Over the years my commute has naturally become an opportunity for me to take stock of the day. I like to take stock of things, sum them up. This is especially true of work, where I don't have the time or space to emotionally process during the shift. I do a kind of final evaluation, sorting my experiences and trying to put them away before I get home. <br />
<br />
The trouble is, I'm never satisfied with my own performance.<br />
<br />
Is it a win that I stabilized a transplant patient enough to make it to her critically important transplant meeting tomorrow? Or is it a sign that I can't manage patients efficiently, since it meant she was with me for nine hours? Does it mean something that she and her husband thanked me when I checked in with them one last time before I left, two hours after the end of my shift? Or should I focus on the mother of the child with an earache who had to wait two hours to be seen while her son cried in pain? She told me off pretty soundly when I finally got in the room. I couldn't tell her that I had been prepping and transferring a patient with intracranial bleeding and coordinating care for my first ever case of acute angle closure glaucoma, and I didn't mention that we were short a doctor that day. My instinct isn't to defend myself in those situations. I just apologized.<br />
<br />
I saw so many sick patients today. Bowel obstructions, cancer complications, my transplant patient. Two patients with heart rates sprinting away, their owners pale and panting for breath. I reassured a post-stroke patient that their recovery was just beginning. I kept someone out of a nursing home by helping to arrange for assistive devices at home. I made two little kids laugh during their exams! My boss is right. She did a good job today and so did I, damn it. So why don't I <i>feel</i> like I did?<br />
<br />
Maybe it's because we were so busy. My charts aren't finished. Wait times were long. That kid with the earache? He wasn't the only one who had to wait a long time, and people were annoyed about it. When my night colleague came on, there were patients who had been waiting for hours already queued up for her. She was nice about it, but I know that's a lousy situation to walk into.<br />
<br />
Or maybe there's no external reason. I know one of my strongest traits is perfectionism; it's a double-edged blade that medicine has sharpened and hardened over time. I don't know what today would have had to look like for me to feel like I did well. I just know that I always feel like I'm not disciplined enough, not knowledgeable enough, not efficient enough, not fast enough. Not kind enough. Not consistent enough. Not enough.<br />
<br />
I still don't feel like I'm enough.The Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.com0tag:blogger.com,1999:blog-1658844413081032183.post-31802722674085286612019-07-12T19:19:00.000-05:002019-07-22T19:17:37.345-05:00The Importance Of The PhysicalMy charge nurse stepped out of a room and waved to get my attention. "We need a doctor in here, please," she said in a level voice. In non-ED-charge-nurse speak, this roughly translates to, "GET IN HERE RIGHT FREAKING NOW THIS PERSON IS DYING." I dropped everything and headed in.<br />
<br />
<a name='more'></a><br />
As I entered the room, three nurses were bodily lifting a youngish-looking woman out of a wheelchair and into bed. Her head lolled as they moved her, then she seemed to go rigid and tremble for a moment. The charge nurse spoke what I was thinking. "We saw her shake like that a few minutes ago as well. Maybe she's having seizures? Her friend just dropped her at the front door and left."<br />
<br />
I leaned over her as she went limp and groaned. I saw a fresh scrape over her left temple. "Honey? Squeeze my hand. Squeeze my hand!" Nothing. The nurses stripped her and placed her in a gown - skin looked normal, no rashes, no bruising - then I peeled back her eyelids and shone a light in her eyes. The pupils winked back at me sluggishly. The nurses were feverishly getting her hooked up to our monitors. I looked up. The blood pressure and pulse ox weren't reading... or were they? The pulse ox signal was weak and unreliable but it read 56. "Let's go ahead and put oxygen on her. Do a nonrebreather in case that number is more real than it looks.<br />
<br />
"Do we know anything about her? Name, age? Did the friend say anything about whether she's been sick?" I continued my exam as I spoke. Neck felt supple, no swelling. A quick listen over the chest confirmed the whisper of air in both lungs. My charge nurse looked up from where she and the other nurses were trying to get IV access and shook her head. "Not really. I think the friend said something about a fall a couple of days ago, or maybe just a fall today, that she passed out. She's got a lot of track marks and it's making an IV hard."<br />
<br />
That was enough to get started with. A hard fall can lead to bruising or even bleeding on the brain, and a bad skull fracture can displace and cause increased pressure on the brain. Any of those things can lead to seizures, or aggravate an existing seizure disorder. Or maybe there was something else going on. I could only work with what I had.<br />
<br />
"Okay, get her to CT once we have a blood pressure - is the cuff not working or what? Maybe try getting a pressure with a manual cuff. I want to scan her head and neck." I pressed on her abdomen just for completeness' sake - <i>wait a minute. Her abdomen is firm. What the what?</i> A normal, healthy abdomen is soft to the touch. I pressed again and the patient groaned. My eyes shot up to her face. I pressed a third time, cautiously. The patient grimaced and her hand twitched up to mine as if to push me away.<br />
<br />
"Guys, I think we need a pan scan. I don't know what's going on with her but her abdomen is rigid and she gave me the only response we've gotten when I pushed on it." The charge nurse and I frowned at each other. What on earth was going on here?<br />
<br />
One of the other nurses whooped in triumph. "Got an IV! She's got a carotid pulse but no radial, by the way. I think she's probably pretty hypotensive."<br />
<br />
"Okay. Start a liter of fluids. Start a second one once we have access, please."<br />
<br />
500ml of fluids later, her BP had risen from undetectable to 54/32. We dumped another half liter in, then the nurses ran her down the hall to our CT scanner. I grabbed her ID to look her up in the computer, my mind whirling with a vast differential. Drug overdose? Sepsis? Perforated bowel? The sequelae of heatstroke? Seizure disorder? Her chart was not very helpful. No history of seizures that I could see; no history of anything, really, other than drug use.<br />
<br />
The charge nurse ended the phone call she'd just taken. "Hey, that friend is back in the waiting room apparently." She and I went out to meet her. The friend was groggy in the way that only a freshly drugged heroin addict can be, her speech slow and unconcerned. "Yeah, I don't really know what happened. I think she fell off a roof a couple of days ago, is what I heard. I wasn't there. No, I don't know how high. The second floor, I think, that's where she lives. Oh wait, maybe it wasn't the roof. Maybe it was the porch? She hasn't been right since, though. She passed out a lot more today so I tried to take her to go get a drink and she passed out at the store, so I brought her here."<br />
<br />
<i>She fell off a roof. Or a porch.</i><br />
<i><br /></i>
<i>She fell off a roof two </i>days<i> ago.</i><br />
<i><br /></i>
<i>She fell off a roof and she's been passing out ever since</i>.<br />
<br />
All at once, my brain switched directions at full speed, like a train picked up and put down on a different set of tracks. This wasn't a patient with infection or an overdose or a seizure disorder; this was a trauma patient with a dangerously delayed presentation. She needed not just fluids but <i>blood</i>. And surgery, if her abdomen was anything to go by. The charge nurse and I shared a look, thanked the friend, and sped back into the department.<br />
<br />
As I got back to my desk, my phone rang. It was my radiologist. <a href="https://doctorpractice.blogspot.com/2018/10/sometimes-they-live.html" target="_blank">You never want a call from your radiologist.</a> I answered, braced - I thought - for bad news.<br />
<br />
"Hey, is this patient dead?"<br />
<br />
"<i>What?! </i>No. Close, but no. Why, what'd you find?"<br />
<br />
He rattled off a list of injuries that left me speechless. There was air around the lungs. There was air around the <i>heart</i>. The ribs and sternum were more broken than intact. Her abdomen now housed multiple ruptured organs, and a great pool of blood gathered in the pelvis.<br />
<br />
After that point, it was pretty straightforward. I sedated and intubated her, gave her 2 units of blood, and sent her to my nearest trauma center for further treatment*. She had a rough go of it in the trauma ICU, but the last I heard she's actually improving and expected to recover.<br />
<br />
Now, what would you say was the most pivotal point in this case?<br />
<br />
Some might say it was when I heard the full story from the patient's friend, since that's when I put all the pieces together. Some might say it was when I got the CT report back and learned how badly injured my poor patient was.<br />
<br />
But I say it's actually very early on, when the nurse checked a radial pulse and when I pushed on the patient's abdomen.<br />
<br />
You see, prior to that, we had a very sick young woman in front of us and no information. But those two pieces of physical information totally changed our course of action. The radial pulse roughly corresponds to a low-normal blood pressure (systolic around 90). Without it, you know the blood pressure is low - too low for our automated BP cuff to initially give us a reading. We started fluids immediately and I truly think this step was the initial lifesaving decision.<br />
<br />
Now consider if I had not pushed on my patient's abdomen. There were no external signs of trauma that would have led me to get a scan of her belly. The history from the friend didn't come until later. And the scan of her head/ neck was pretty normal. So I would have been left with an extremely sick patient who had some kind of fall and had normal head/ neck imaging. Maybe I would have gotten a scan later (likely when her full panel of labs came back abnormal), but who knows what kind of delay there would have been, and what would have happened to my patient in the meantime.<br />
<br />
So my personal takeaway from this case is to never ever neglect the physical exam. In this age of modern medicine, it's easy to get lazy and rely on labs and scans. Some doctors don't even bring their stethoscopes in the exam room anymore. <i>The physical exam is dead</i>, they say. <i>Long live technology and a good history.</i> And sometimes you can still practice good medicine that way.<br />
<br />
But sometimes you can't.<br />
<br />
And sometimes a physical finding or two can totally change a patient's outcome.<br />
<br />
<i>Long live the physical exam</i>, I say. And hopefully it helps my patients live too.<br />
<br />
---------------------<br />
<br />
*For the medical people reading this who are gnashing their teeth and yelling at their screens, wondering why I didn't place chest tubes before transferring her, the answer is that I made a judgment call. Her pneumothoraces were small and stable after intubation, she was tolerating the vent fine, and the ambulance arrived quickly to transfer her. Chest tubes take like two minutes to put in - until they <i>don't</i> for some unforeseen reason, and then they take ages. I elected not to delay transfer since she was stable enough to go.The Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.com0tag:blogger.com,1999:blog-1658844413081032183.post-4564621931814454742019-06-29T11:31:00.000-05:002019-06-29T11:32:01.235-05:00Boundaries, or, Sometimes I'm An Idiot"Hey, so..." I exhaled. "This second job is getting on my nerves. Wait, I don't think I told you. I got a second job a few weeks ago."<br />
<br />
There was a pause on the line, then my best friend said, "<i>What?! Why?!</i>"<br />
<br />
Let me tell you why.<br />
<br />
<a name='more'></a><br />
Looking back, I only ever worked one paying job at a time when I was younger, and then somehow I got in the habit of having a side gig. I was a TA and did some tutoring in medical school. I did some urgent care and ER moonlighting while I was in residency. As an attending I did a little teaching at my alma mater medical school as a lab instructor. If I'm being honest, I always felt like I was working too much, but I liked my side jobs and we have several hundred thousand dollars of debt, so I kept them. When I was diagnosed with CMT, though, one of the big things I did was cut back on how much I was working. I had been doing about 1.2 FTE at my main job and teaching a couple days a month. I resigned from my teaching position and cut out a couple shifts.<br />
<br />
For a while, that was fine.<br />
<br />
Then I started to get antsy.<br />
<br />
<i>Am I doing enough</i>? <i>Maybe I'm not working enough. I need to expand my skill set. I need something that is less physically taxing</i>. I started looking into my old residency-era leads for non-clinical jobs, relics from when I was trying to get out of medicine. And I remembered one path that had seemed promising before but wasn't an option for a new doc with little experience: chart review.<br />
<br />
Chart review is basically an insurance thing, although it generally isn't under an insurance company directly. Instead it's through something called an independent review organization. When something gets denied for coverage by a person's insurance company, it usually gets appealed. Those appeals go to an independent review organization, where they are reviewed by a doctor in the same field as the original doctor. The reviewer looks at the documentation provided and makes a recommendation as to whether or not the service/ medication/ what have you should be paid for by the insurance company. So basically, you sit on your butt at home and read through some charts and do a little typing.<br />
<br />
I copied a physician blogger I read (sadly, his website is defunct now) and went onto the website where all the accredited chart review companies are listed, compiled a list of options, and emailed my CV out. I shied away from ones that quoted Medicare jargon on their front page or that seemed like they would expect a specific outcome from my work (i.e. expect me to side with the insurance company all the time). I emailed them whether they said they were hiring or not. All in all, I'd say I contacted about 20 companies. The worst they can do is say no, right?<br />
<br />
I had two job offers in like four hours.<br />
<br />
Getting a chart review job felt like plucking a job off the proverbial job tree. <br />
<br />
So I sold out. I turned to the Dark Side. <i>I took a non-clinical side job</i>.<br />
<br />
At first, giddy with the easy win, I threw myself into it. I completed orientation and started reviewing cases as soon as possible. With the company I work for, they text you to offer you a case and you can decide to accept the job or not. I started hitting 'accept' on nearly everything they sent me. And surprisingly, I've found I don't mind the work. Most of it is low-stakes stuff about if a blood test was necessary or something. Sometimes it's interesting. Sometimes I find a reason a service should be covered and I know I'm helping the patient. As desk jobs go it could certainly be worse. The company was appreciative; I got a couple of emails and texts praising my work ethic and accessibility.<br />
<br />
Then I realised I was grumpy all the time, and also that I never had a day off. I mean <i>never</i> - on days off from my main job I was spending a couple of hours a day doing chart review. Sure, that's no 12-hour shift, but it's also not the same as truly not working. I was getting texts every day from the chart review company, asking me to do cases. <i>You're so much more available than the rest of your panel</i>, they said. Then they asked me to review a massive case with over 100 pages of documentation, on a topic I've never managed before. I said no. They asked again. I said no. Then they asked a third time and I caved, and it was, predictably, horrible. I spent hours just reading up on the topic and digging through relevant literature, then another hour or two reading through the chart notes. Then I spent another hour on the phone with one of the medical directors answering my questions and providing guidance. <i>Then</i> I had to <i>call the original doctor</i> as per the insurance company's requirement. Then I could, at last, spend an hour typing up my conclusions and submitting my report.<br />
<br />
Did I mention they only give you a 2-3 day turnaround time?<br />
<br />
Did I mention I get a standard flat fee per case reviewed, regardless of the length/ complexity?<br />
<br />
Did I mention this is <i>not my main job?</i><br />
<br />
My friend was not sympathetic. "I mean, Zoe, it sounds like you're working too hard again. You should probably stop that. Just start telling them no."<br />
<br />
Affronted, I started to argue, then let her criticism sink in. It jolted me into a little self-awareness. What was I complaining about? No one made me take this job. This place didn't recruit me; I basically cold-called them. I don't, strictly speaking, have to do this. And I certainly don't have to do this at 100 miles an hour.<br />
<br />
"Uh, yeah. Yeah, you're right. I'll work on it."<br />
<br />
I could picture her nodding in approval. "Good. Stop working so much, I feel like we've talked about this a million times."<br />
<br />
The whole ordeal reminded me of some things.<br />
<br />
1. Companies are not there to take care of you. At best, they care about getting the work done.<br />
<br />
2. You need to set your own boundaries.<br />
<br />
3. Sometimes you will have to defend those boundaries against your employer.<br />
<br />
4. Your employer depends on you for #2 and #3.<br />
<br />
I think the last point is the most important one. If you say yes to some kind of work, your boss will assume you said yes because you're okay with doing it. If you're not okay with doing something, guess what? You have to say no.<br />
<br />
So I started doing just that. I made a little pact with myself: no more cases over 50 pages long, no more cases where I don't already know a lot about the topic at hand, and no more cases where I have to call other doctors. I've already had two other instances where they pressured me to take another beast of a case, and I replied simply, "I'm sorry. I can't," and that was the end of it. They texted me once while I was at my regular job and I politely informed them that I do not take cases on days when I work and reminded them that my unavailable days were given to them per their request. I've decided that I am keeping the job for now; I'm learning some new stuff and making a little extra money, so it's worth it. But from now on it'll be on my terms.<br />
<br />
I get fewer texts from them now. I get some days off.<br />
<br />
And I am a lot happier.The Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.com0tag:blogger.com,1999:blog-1658844413081032183.post-23225051239879165232019-04-21T20:25:00.000-05:002019-04-21T20:25:36.856-05:00Listen. Listen. Listen. Listen.<i>I am not doing this anymore</i>.<br />
<br />
It was Tuesday, I was in the occupational therapy clinic for just the third time, and I hated it already. The first visit consisted of testing my weak, uncoordinated hands; picture me failing to pick up tiny metal pins and put them in tiny holes, and then bursting into tears. The second visit was full of painful exercises that left my hands limp. Today I was doing silly putty exercises under supervision and it was making my arm cramp.<br />
<br />
I threw the putty down on the table.<br />
<a name='more'></a><br />
"I don't think I should do any more of those. They seem to be making me worse, and I have to work later today. It's hard enough to make it through a shift even without that."<br />
<br />
Linda*, my occupational therapist, paused, then agreed. "Okay. Maybe these exercises are too much for you." She paused again. "I think you should consider..."<br />
<br />
I looked at her dully, full to the brim with frustration. "What?"<br />
<br />
She visibly gathered herself. "I think you should consider whether you can continue to do your job. It might not be feasible for you anymore."<br />
<br />
I fired her after that.<br />
<br />
I have developed a newfound sensitivity through my role as chronic patient, specifically to feeling like people are on my team. I have a very simple way of describing this.<br />
<br />
1. Do they understand what I want from my life?<br />
<br />
2. Are they willing to help me achieve my goals?<br />
<br />
Notice I'm not interested in them achieving <i>their</i> goals. It's not that I'm ignorant of the fact that providers may come in with their own agendas when it comes to my disease. I just don't care. That's because when you're talking about issues of long-term function, there are very few black-and-white answers. More often things are very contextual and individual; what works for me may not work for you, and vice versa. This means someone has to know what I want in order to help me get it.<br />
<br />
As I've thought about this more, I realised this actually applies pretty widely. I think it feeds back into the concept of patient autonomy. Patient autonomy is a fairly new thing in medicine, having come into being over the last 100 years or so. Before that a doctor was expected to dictate what the patient did according to what the doctor thought was important. This was called beneficence, or paternalism. Modern medicine is quite different. As a modern physician, it is NOT my job to decide what my patients should do.<br />
<br />
Let me say that again. As a physician, it is NOT MY JOB to decide what my patients should do.<br />
<br />
What is my job? Finding out what my patients are looking for and helping them get that in the best way possible. There are several parts to this. I need to figure out what my patient wants and what they know about their circumstances. I need to give appropriate information and make them aware of their options. And then I get to help them move forward with the option they choose.<br />
<br />
Sometimes that's pretty straightforward. A person with an infection would like the infection cured; a person having a heart attack would like the heart attack treated. In those situations, the discussions are short and simple. But most of the time it's a lot more complicated. A person with chronic depression or anxiety comes to the ED looking for narcotics to numb their mental pain, ignoring the dangers of addiction. A person with terminal cancer is not sure whether they want to live <i>longer</i> or live <i>better</i>, or doesn't understand that at this point in their life, those two paths have forked away from each other. A person with diabetes wants mutually exclusive things, perhaps - to eat an unhealthy diet but also to avoid insulin therapy and complications of their disease. There's a lot more discussion that has to take place in these scenarios. In all cases, though, a healthcare provider needs to know what their patient wants and assess the patient's understanding of their own situation before providing recommendations. The patient may choose something I disagree with. That's okay. It's not my job to tell them what to do.<br />
<br />
Here is why this is also relevant to me as a patient. That occupational therapist was not listening to me when I told her that I love my job and plan to stay there as long as possible, and she was not invested in helping me do that. Instead she did her best to quantify the degree of my disability and then essentially told me to quit the job I trained for and fought to get. It felt like Linda gave up on me; I didn't fit into her system and she decided I just couldn't achieve what I wanted.<br />
<br />
You know what my second occupational therapist did? She guided me through a detailed discussion of my goals and challenges and assessed my current function. And then she told me to get a different kind of wrist brace that would let my hand rest better while using the computer. She's helped me with many other things as well, but I'm not exaggerating when I say that that single suggestion, made carefully and with the right information in mind, has allowed me to stay in practice over the past year. Over and above that, though, it means a lot that she listens to me and has worked with me where I am. And I think it's taught me something about taking care of my own patients. I think every patient wants to know that their doctor is on their team and cares about the things that are important to them. For me it means asking more questions and making fewer assumptions.<br />
<br />
Probably a good approach for me to take in the rest of my life, too.<br />
<br />
------<br />
<br />
<i>*Linda is not this therapist's real name. </i>The Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.com1tag:blogger.com,1999:blog-1658844413081032183.post-1311802767168220892019-01-28T08:07:00.000-06:002019-01-28T10:41:04.293-06:00Disability: Having A Sound BiteGasps greeted me as I walked into the exam room. "Oh my- what <i>happened</i> to you?!"<br />
<br />
Caught entirely off guard, I struggled for a response, but blanked. There was an awkward pause in the room. The problem was...<br />
<a name='more'></a>...that nothing was wrong. I had just acquired a new assistive device: a forearm crutch.<br />
<br />
The crutch is new, foisted on me by my physical therapist after he discovered how weak my right leg can get with exertion. Standing for long periods of time or frequent sudden direction changes fatigue my thigh muscles quickly on bad days, and those are things I can expect to have to do frequently in my work. So the crutch, just one, held in my left hand on days when I need the help. I have a complex relationship with it. I appreciate what it does for me, supplementing my weak leg and greatly augmenting my physical abilities. On procedure-heavy days, it's a game-changer for me. But I also hate it. It is cumbersome, it occupies one of my hands, and worst of all, it is <i>visible</i>. <br />
<br />
It's hard to feel like evidence of my condition is on public display. Before this past year, I had no idea how much courage it takes sometimes to go out in the world as a person externally marked as different, as less able. And that's true just going to the grocery store. At work it's even harder.<br />
<br />
All of which leads me back around to my current problem: patients often exclaim in dismay when they see the crutch. I'm not sure what they think happened to me, but they clearly imagine some kind of catastrophe. I get comments about the wrist brace I wear, too, but those tend to be more casual; lots of people wear a wrist brace, for a variety of reasons. This crutch, though... it seems to really concern people. Some patients cry out as soon as I walk in. Others try to contain themselves for a while. I watch their eyes go to it when I enter the room, rather than directly to me. Often they have to ask for my name multiple times because they weren't listening yet when I started talking. Whichever path they take, both end at the same place: what is that? Why do you need it? Are you <i>okay</i>? I can't help but feel that the answer is important to them somehow.<br />
<br />
I wonder, too: if I make it too clear that I have a disability, will it affect their perception of my safety as their physician? I know that I would never put my patients in a situation where they could not safely get the medical care they need, but do they trust that?<br />
<br />
So what do I say about this crutch? Through trial and error I have found the most important features my answer needs to contain. First, it has to <i>be an answer</i>; pushback invariably escalates into tension. It has to be serious, because a clever joke often just leads to more insistent questions. It can't be too long or personal, because they are not really there to talk about me and I'm not there to lecture them about my condition. And it needs to be straightforward, because something mysterious or evasive tends to backfire on me - on occasion, it's even caused the patient to get belligerent about demanding a proper response (as to why patients feel they are owed information on my personal life... who knows, but the exam room is not the place for me to try to figure that out). The ideal response, then, is a kind of sound bite. Short. True. Uninteresting.<br />
<br />
For my wrist, I've settled on, "Oh, it's just a little sore today."<br />
<br />
For the crutch, saying, "Oh, it helps me with my balance," seems to go over the best. If they still have questions (which is rare), I simply say I have neuropathy and leave it at that.<br />
<br />
Having a quick conversational tool is invaluable in helping everyone in the room get past my devices. <i>Why</i> do those two sound bites work well? I have no idea! But I'm glad to have something in my back pocket to help me navigate these conversations. Ultimately, with or without the crutch, my goal with a patient is always the same: to get them comfortable with me so we can focus on the real matter at hand.<br />
<br />
"So tell me about what brings you to the emergency room today."The Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.com0tag:blogger.com,1999:blog-1658844413081032183.post-58577626298557144852019-01-17T00:10:00.001-06:002019-01-28T10:41:29.790-06:00(Sporadic) Money Update: 2018, or, Imagine Me Rolling My EyesI am so sick of paying down debt. So let's talk about it!<br />
<br />
My husband and I are in the middle of this debt-paying thing. At this point we have completed several of the most important steps:<br />
<br />
- figured out how much debt we actually have, which is horrifying but necessary<br />
- <a href="https://www.whitecoatinvestor.com/student-loan-refinancing/" target="_blank">refinanced </a>all of our loans for a lower interest rate (which will save us approximately $40,000 over the life of the loan)<br />
- sucked it up and started paying ridiculous amounts of money on our loans<br />
<br />
That means that we are in the "paying ridiculous amounts of money" stage.<br />
<a name='more'></a> On average, 40-50% of our take-home pay goes directly to loans. That's to pay the minimum on everything. So we pay it. Every month, we pay it. We pay it, and we pay it, and we pay it and pay it and pay it. And still there's more.<br />
<br />
So where are we after about two years of payments? We started formally tracking our debt in January 2017. At that point we had already been paying things down for about four months, and we owed $472,016.32. Our new debt total as of Jan 1 2019 is... drum roll please...<br />
<br />
$369,580.07.<br />
<br />
I gotta say, being in the middle of paying down over $500,000 is a drag. I mean, is that second number even lower? Are we making a dent in this? Supposedly if we keep things up at this rate, we will be debt free except our mortgage in another five years*, but right now it feels like we're throwing money down a bottomless pit. We're not filling anything in. We can't even hear it hit bottom. It just silently disappears.<br />
<br />
I think it's important to note that paying debt isn't the only thing we are doing with our money, at the behest of our financial advisor. He told us to prepare for the future and also to live our lives. Because of this we clearly are not strict (or loose) adherents to the Dave Ramsey method. We maxed out my 401k last year. We have a properly stocked emergency fund with several months' of expenses tucked away. We even made a small addition to our house last year. And it's all great, but I hate it at the same time because I will never feel like we are making meaningful financial progress until our debt is going away.<br />
<br />
<i>Okay, if you're so sick of paying debt, why not move under a bridge and put all of your money towards your debt for a couple years?</i> Because that would be stupid, that's why. Bridges are cold and there's nowhere to cook dinner down there. But I see your point. There's room for us to tighten our belts and get more aggressive with our debt, or at least there was last year. This year, there's no rocking the boat until we know what things will look like financially.<br />
<br />
I guess we will just keep paying the same payments for now.<br />
<br />
::eye roll::<br />
<br />
------<br />
<br />
*We have several different loans and they all have different terms. The smallest loan should be paid off in about a year; the next smallest, about a year after that. Then all that's left are the big ones, which should be paid in full sometime in 2024. They talk all the time about how doctors are really good at delayed gratification, but I cannot overemphasize how impatient I feel about getting rid of these loans. So five more years = an actual eternity.The Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.com0tag:blogger.com,1999:blog-1658844413081032183.post-31624619917682174242019-01-07T20:01:00.000-06:002019-01-28T10:42:13.975-06:00Uncertainty, or, 2019: Midnight TracksI love planners; I'm a bit obsessed with them, really. I've always had one. I think by nature I'm a plan-maker, someone who takes the long view. Years of practice and training have taken my penchant for journalling and turned me into a list-maker as well. At this point, if I don't have a formal planner, I eventually clutter up my life with piles of to-do lists and thought fragments. This year, when it became fatiguing to write, I tried to abandon my paper planner for digital alternatives that I can talk into, but it's not the same. So a 2019 paper one it is. Usually I get something with monthly and weekly pages, and room for notes - pretty standard. My planner choice* is different this time, though. For the first time, I want a goal-setting planner, I think for several reasons.<br />
<br />
<a name='more'></a><br /><br />
For years, I have lacked a lot of control over which goals I pursue and how. It's part and parcel of medical training; if you want to be a doctor, your life is going to look a particular way for a long time. Someone else tells you how much you are going to work, what you're going to work on, etc, and that process doesn't leave much room for other things. Even when I got off the training treadmill, I was working quite a bit. But with everything that happened this past year I made the decision to finally work less, and I've scaled back a lot the past six months. It's freed up a lot of time that I'm not sure what to do with. I don't want to get stuck in a rut so early. I like the sense of satisfaction I get from choosing a project and completing it, or taking aim at a challenge and conquering it.<br />
<br />
If I'm being perfectly honest with myself, though, that's not the only reason. I want control back. Remember when I said I feel like 2018 happened to me? I don't want that for a second year in a row. And there's so much about this coming year I can't possibly control that I feel the need to control what I can and make sure I do it right. Which brings us back around to the uncertainty of my circumstances.<br />
<br />
I don't know much about how things will go this next year, and that scares me. Don't give me any crap about how "technically no one knows what the future holds" - most people can reasonably predict how the coming year will go, barring catastrophe. But where will I be in six months? Will I still be able to safely, confidently work in emergency medicine? If not, what do I do for work that won't make me miserable? Will I still have the use of my hands? How will my personal functioning change? How will our finances be affected? Speaking of finances, my husband starts a new job this year with uncertain income, a big change from his previous salaried position. So neither of us can really be the safety net for the other. So... there's no safety net.<br />
<br />
We are launching into this thing, ready or not, no parachute, no seatbelts.<br />
<br />
Which is not okay with me! I cannot plan my way out of this uncertainty! I have no way to make sure I know what's going to happen! And anything could go wrong!<br />
<br />
...It's probably time to take a deep breath.<br />
<br />
Okay, a few deep breaths.<br />
<br />
This planner can certainly help me dream and set some tangible goals. But it can't take away my grief over my condition or fear of the unknown. It can't give me courage to face the future. Only God can do that. And only if I let Him.<br />
<br />
----<br />
<br />
I woke up this morning with a song in my heart. It's called "Wherever You Go" by Audrey Assad, and the first verse goes like this:<br />
<br />
<i>There's a train leaving your heart tonight</i><br />
<i>There's a silence inside your head</i><br />
<i>You're running</i><br />
<i>You're running from me</i><br />
<i>Down the tracks on a midnight line</i><br />
<i>There's a red moon in the sky</i><br />
<i>You're running</i><br />
<i>You're running from me...</i><br />
<br />
I didn't know at first why that song kept playing through my mind, but it lay on me heavily all morning, letting me know it was more than just another melody stuck in my head. Then I realised. It's a song about running from God in the face of suffering, and the further suffering that comes from that, and how He pursues us faithfully, always ready for us to come back to Him. It took that song and a sermon on Ezekiel 37 for the true extent of my crushing anxiety to become clear to me. It's hard for me to accept that God may not spare me more pain; that's not a promise any Christian is given. It's hard for me to trust that His ways are good even when they're painful.<br />
<br />
But what, like my ways are better?<br />
<br />
God is not a fallible, limited human; he's <i>God</i>. And He loves me, not in the flawed way a human loves, but with a perfect, selfless, unfailing love. How could I not trust Him?<br />
<br />
Today, for the first time in several months, I looked at all my worries and merely felt content. "God will take care of me," I thought.<br />
<br />
And He will.<br />
<br />
-----<br />
*If you're wondering what I chose, I eventually decided on one of those construct-your-own planners from <a href="https://inkwellpress.com/" target="_blank">Inkwell Press</a>. Pricey, yes, but in theory reusable, and it had the modules I wanted. We'll see how I feel about it.The Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.com0tag:blogger.com,1999:blog-1658844413081032183.post-84307992687116832192019-01-01T00:03:00.000-06:002019-01-28T10:42:28.420-06:00Uncertainty, or, 2018: A RetrospectiveWhat a year.<br />
<br />
Did anyone else have a really eventful 2018? I certainly did. The time passed so quickly that I'm tempted to say not much happened, but that is completely wrong. Enough happened this year - and enough is happening next year - that I've decided to do something I've never done before and try to look back on the year as a whole.<br />
<br />
<a name='more'></a><br /><br />
On the professional side, I changed to full time emergency medicine. That was something I'd given up on years ago even though it's what I'd originally wanted - in fact, was what I wanted right up until I stopped wanting anything from medicine. But this year I feel like I got to live my best EM life! I attended my first big national EM conference, which was a blast. I saw a whole bunch of things I've never personally managed before, from severe carbon monoxide poisoning to being a bystander on scene at a trauma (terrifying! never again!) to <a href="https://doctorpractice.blogspot.com/2018/10/sometimes-they-live.html" target="_blank">adult intussusception</a>. Overall I feel like I grew from a junior member of my group into a more experienced and reliable physician, and I really like that. I can tell I've racked up professional trust with my colleagues; it isn't that I ever did something to make them <em>not</em> trust me, but rather that there's no shortcut. People have to see that you know what you're talking about before they will rely on you, and that takes time. It's a privilege to know I'm putting that time in. It's a gift to enjoy medicine again.<br />
<br />
Even though my job is very exciting by nature, I arguably had a more tumultuous personal life this year. I had the privilege of travelling to no less than three weddings this year, all for friends/ family I love dearly. Given the amount of important life stuff I've missed over the past ten years, this was pretty heady stuff for me. I started to write again after a years-long hiatus. I had a totally undangerous but very real brush with PTSD (did I not tell you about that? A story for next time). Because of that, sleep has been a fickle friend, at times leaving me so exhausted I'm nearly seeing double. My husband made the decision to change career paths both much earlier and more drastically than we originally anticipated. Oh, and I was diagnosed with an <a href="https://doctorpractice.blogspot.com/2018/08/news.html" target="_blank">incurable, progressive neuromuscular disorder</a>.<br />
<br />
I mean, that's a lot, right?<br />
<br />
With all the ups and downs, the travel every other month, the <em>massive life-changing</em> <em>upheaval</em> of my condition, by the end of the year I was emotionally tapped out. It's why I haven't posted much lately. I worked Thanksgiving and Christmas and my husband and I didn't go anywhere or see anyone. The quiet has allowed me to start to get my bearings somewhat. I'm used to feeling like I accomplish things every year, but this year I feel very much like 2018 happened to me, like I was a passive recipient of the events in my own life. I think I'd like to reclaim some agency.<br />
<br />
You know, for most of my life, things have felt almost like they were on rails. I don't know if anyone else can sympathise with that. I chose a career that is very demanding, yes, but at the same time has a very defined track. I remember saying to myself countless times that all I had to do was <i>follow the plan</i>. High school. College. Med school. Residency. Just follow the plan and everything would turn out. And I suppose it did, more or less. But I am thoroughly out of plans now, and I've never been in this place before. I reached the end of the list. I've run out of rails. How could I not have noticed that all my plans petered out around age thirty? Although I suppose it wouldn't have mattered if I had planned clear out until I die at age 82; I never could've foreseen where I am now. I had no idea I would be diagnosed with Charcot-Marie-Tooth disease or the extent to which that would change my life.<br />
<br />
And so here I am. No plan, a checked-off list. I'd actually be content to cruise along like this for a few years, just study and work and live and improve in my faith and my craft and my relationships, but because of my disease I don't think I'll get to do that. It won't be the way everyone else gets to do it, at least.<br />
<br />
So... now what?<br />
<br />
What the hell am I meant to do now?<br />
<br />
Where will I be in a year?<br />
<br />
For the first time in my life I honestly cannot say.<br />
<br />
Perhaps the better question is this. How do I face the uncertainty of the rest of my life, both short- and long-term, and to what extent do I try to plan?The Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.com1tag:blogger.com,1999:blog-1658844413081032183.post-51480025216761502732018-12-12T23:03:00.002-06:002019-01-28T10:42:49.977-06:00Reflections on Primary CareJust because I haven't written about burnout in a while doesn't mean I don't still care about it.<br />
<br />
Over the past year or so, I've become an avid, sympathetic reader of a blog called <a href="https://reflectionsofamillennialdoctor.com/" target="_blank">Reflections of a Millennial Doctor</a>. The author, M, vividly details her struggle with burnout and giving up on primary care. She fought so hard this past year, wrestling with whether or not to stay in her current practice or throw in the towel and try her hand at something else. She recently admitted that she will be leaving her practice soon for a job as a hospitalist. I can relate - not to the hospitalist part! I hate hospital medicine. But her tale of getting bled dry by her clinic job resonated with me deeply. Honestly, I don't know how her primary care dreams survived her training. <a href="https://doctorpractice.blogspot.com/2016/08/the-other-side-of-disillusionment.html" target="_blank">Mine didn't</a>.<br />
<br />
I remember being a medical student and writing an essay about <i>the importance of trajectory change</i> for my family medicine residency application.<br />
<a name='more'></a> The goal of primary care, I wrote, was prevention through education and support of healthy habits. The reasoning is this: if you can get a person to make small healthful changes now, those will yield more and more benefits as the person gets older. You can change the trajectory of their health long term. It seemed elegant, noble, necessary. I pictured myself as a healer walking with my patients through their highs and lows, providing gentle guidance as they lived their best lives.<br />
<br />
It all sounds like so much romanticised horseshit now.<br />
<br />
Okay, I'm being unfair. Not <i>horseshit,</i> precisely. But close. You see, while the theory still sounds reasonable, I never saw any evidence of patients beginning trajectory change while I was in residency. We would set goals together, and they would fail to start taking their medication or checking their blood sugar. I would hand-write instructions. They would never make that fabled appointment with a therapist. I would encourage, give hugs, follow up by phone. The visits were often very positive. But they never started going on those ten minute walks. They never started working on sleep hygiene. They never cut down on their smoking, or alcohol, or Dr. Pepper, or street drugs. They never added in that daily vegetable. They came to me for help, but never seemed to do anything I asked them to do.<br />
<br />
Except come back. They were always willing to come back and see me, <a href="https://doctorpractice.blogspot.com/2016/12/complex-redemption.html" target="_blank">sometimes for months on end</a>. I spent about a year wondering why people were so happy to come and recycle through the same spiel of mine over and over again while doing exactly zero of the things they said they would do. Eventually I realised it was at least partly because of me personally. They liked <i>me</i>. They liked talking to me, spilling their problems to a sympathetic ear. They liked that I believed in them, not because it actually galvanised them to change, but because I was nice and that felt good. Realising that I had become an emotional ATM - that I was no source for solutions but instead just a new component of their problems - signalled the beginning of the premature end of my primary care career.<br />
<br />
Those patients broke something in me, not like a bone that heals and grows strong again, but like a glass vase that, once shattered, loses both its present and future potential for function. All you can do is clean up the mess. You try not to get cut on the pieces as you go. Eventually you replace it with something uglier but more durable; I am not capable of investing to the degree I once was.<br />
<br />
Just like M, I pulled the chute. Unlike her, I had no optimism left after residency, so I yanked that ripcord way earlier. I actually applaud her for giving primary care a try for a while to see if it was different after training. I have to say, though, it really doesn't surprise me that she found it to be more of the same. And it doesn't surprise me that she has been driven out by the impossible demands of her job. I can't sustain a job where the patients I'm taking care of have no buy-in with what I'm telling them to do, and it sounds like she can't either.<br />
<br />
God has blessed me enormously by allowing me to get back in the ED, where I discovered that I can still love medicine. I love my job so much now that even in the face of my burgeoning disability, I am determined to fight through to stay in this field as long as I safely can. I truly hope she finds the same.The Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.com1tag:blogger.com,1999:blog-1658844413081032183.post-30612158920233662632018-10-19T23:51:00.001-05:002019-04-21T21:09:09.594-05:00Sometimes they live<div style="background-color: white;">
A patient walked out on me the other day.<br />
<br />
It doesn't happen every day, but it happens often enough. I usually never find out why. Sometimes it's to go pick up children or meet another time-sensitive obligation. Sometimes it's to go smoke a cigarette or get a dose of drugs. I think sometimes they get scared and feel as though running from the department can help them escape their diagnosis. Whatever the reason, I learned early on that I have to be able to let those people go. The other side of the patient autonomy coin is this: they're responsible for getting the care they need and it's not my job to force or coerce them.<br />
<br />
Except when it is.<br />
<a name='more'></a>-------<br />
<br />
"My stomach really hurts."</div>
<div style="background-color: white;">
<br /></div>
<div style="background-color: white;">
I sighed internally. Another belly pain. Any ER doc can tell you abdominal pain is one of the vaguest, most potentially frustrating complaints that we see. It could be anything. Dissecting aorta? Gas pain? Sure, I don't know, maybe. Sometimes it turns out to be a horrible emergency. Sometimes I send dissatisfied patients home without a diagnosis because all of my work up was negative. There's often no way to tell in advance. This lady didn't look too bad just sitting back in bed, although that can be a trick in a patient who is naturally stoic. Vital signs looked normal. I listened to her story.</div>
<div style="background-color: white;">
<br /></div>
<div style="background-color: white;">
"I've never had pain like this, doctor. It's been there for days, just comes and goes, but today it's not going away and it's been there the whole afternoon. It hurts so bad, right here." She gently pushed on the right lower side of her abdomen.</div>
<div style="background-color: white;">
<br /></div>
<div style="background-color: white;">
I nodded, now mildly concerned. Pain that gets worse or is the worst pain a person's ever felt can be a worrying thing. It can also be crap (figurative or literal). She was gesturing to the part of the abdomen that contains the appendix, which is not good, but at the same time she was sitting up and pressing on her own abdomen, which is generally a good sign. On the badness/ not badness scale, she was still squarely in the middle. </div>
<div style="background-color: white;">
<br /></div>
<div style="background-color: white;">
I did a quick exam. The right side of her belly was a little bit tender when I pressed on her. "Do you still have an appendix?"</div>
<div style="background-color: white;">
<br /></div>
<div style="background-color: white;">
She squinted. "I think so?" (You would be surprised how often people are not sure which organs they still have.)</div>
<div style="background-color: white;">
<br /></div>
<div style="background-color: white;">
After another internal sigh, I grabbed her chart and turned to go. "Well, let's check some lab work and a urine sample. I think I'd also like to get some imaging of your abdomen."</div>
<div style="background-color: white;">
<br /></div>
<div style="background-color: white;">
She shook her head. "I don't want any imaging. Can we just do the blood work and see what that looks like first?"<br />
<i><br /></i>
<i>Eh? Whatever, fine. We're not that busy and she doesn't look sick.</i></div>
<div style="background-color: white;">
<br /></div>
<div style="background-color: white;">
A short while later, the patient was saying that her pain was worse despite two doses of IV pain medicine, and all of her bloodwork looked normal except for a slightly elevated white blood cell count. A slight elevation can be a sign of infection, inflammation, or just pain - so again, a completely nonspecific finding. I stopped back in to talk to her. Did she look a little pale? "If you're doing worse, we really need to get a CT scan of your abdomen, especially since you're hurting in the right area for this to be your appendix."</div>
<div style="background-color: white;">
<br /></div>
<div style="background-color: white;">
She grimaced. "That will take a long time, though. Do we really need it?"</div>
<div style="background-color: white;">
<br /></div>
<div style="background-color: white;">
I frowned right back at her, unimpressed. "You tell me. Isn't this the worst pain of your life? If so, don't you think it's worth waiting around a while longer to try to find out what's hurting you so bad?" We went back and forth a couple rounds, but she acquiesced eventually.</div>
<div style="background-color: white;">
<br /></div>
<div style="background-color: white;">
Then she disappeared 10 minutes after the scan was done. No warning, no announcement. She just left. Honestly, I had other patients to take care of. I shrugged and moved on.</div>
<div style="background-color: white;">
<br /></div>
<div style="background-color: white;">
20 minutes later I got a call from the radiologist. You never want a call from your radiologist. It means they've seen something serious enough that it needs to be passed on in real time; they cannot wait for you to just read their report. "Hey, did you get a look at that CT scan? Your patient has an intussusception. Pull up the delay sequence and look at image 47."</div>
<div style="background-color: white;">
<br /></div>
<div style="background-color: white;">
<i>Say what?! In a young adult?</i></div>
<div style="background-color: white;">
<i><br /></i>I pulled up the images in a hurry, and there it was, a couple of tightly nested loops of bowel sitting in the right lower quadrant of her abdomen. The last part of the small intestine had telescoped into the beginning of the colon and gotten stuck there. There were clear signs of edema in the fat around the bowel, indicating that the blood flow had been cut off for long enough that the bowel was starting to die. In these cases, the segment of stuck intestine must be either un-telescoped or removed.</div>
<div style="background-color: white;">
<br /></div>
<div style="background-color: white;">
Intussusception in an adult is a surgical emergency, and my patient was no longer in the department to have her emergency surgery. </div>
<div style="background-color: white;">
<br /></div>
<div style="background-color: white;">
The radiologist and I pondered what to do for a few minutes. After all, she had left without being discharged. Would she actually return? Would it be a waste of my time to contact her? But what person in good conscience could fail to let someone know that they have a serious, urgent diagnosis?<br />
<br />
Of course I called her. She didn't explain why she left, but she also didn't resist my command to <i>get back here right now because you are very sick</i>. She was in surgery by lunchtime.</div>
<div style="background-color: white;">
<br /></div>
<div style="background-color: white;">
The next night the radiologist called me again. He'd checked on the patient and wanted to give me an update.</div>
<div style="background-color: white;">
<br /></div>
<div style="background-color: white;">
"You know they had to surgically remove that intussusception, right? It was so swollen they couldn't reduce it. I'm glad you called her." He paused for a moment. "You know, you saved her life by calling her to come back in." I was taken aback and tried to demur, but he was having none of it. "No, Zoe, if you hadn't called her she probably would have come in way later, septic, and not done well. I mean it, you saved her life." </div>
<div style="background-color: white;">
<br /></div>
<div style="background-color: white;">
I brushed it off at the time, but a few days later his words came back to me. Did I save her life? In the most obvious sense, of course I didn't. The radiologist that diagnosed her did that. The surgeon that took out her intussusception did that. But... I did get the ball rolling by insisting on the CT. And while it was a no-brainer, the phone call I made to bring her back for definitive medical care was undeniably important. Without it, she may have stayed at home until she was extremely sick indeed. </div>
<div style="background-color: white;">
<br /></div>
<div style="background-color: white;">
I think I'm willing to give myself a small sliver of the credit in this case. Sometimes I get more and sometimes I get less, or none at all. But it's nice to see something I've done make a direct difference. Sometimes I get to help save someone's life. Even if it's just with a phone call.</div>
The Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.com0tag:blogger.com,1999:blog-1658844413081032183.post-27751870915827555982018-09-26T07:51:00.000-05:002019-01-28T10:43:29.097-06:00Sometimes they dieHonestly? I hate traumas.<br />
<div>
<br /></div>
<div>
I can't stop thinking about one I got a while back. Auto vs. motorcycle. A nice young man had been driving at dusk - not texting or anything as far as we know - and turned left in front of a motorcyclist who wasn't wearing any gear. He never even saw the motorcycle coming. The driver in the car was fine. The guy riding the motorcycle - another young guy, I never quite learned his age - became our patient. I was the backup doctor in the room but it still felt like he belonged to me.</div>
<div>
<br /></div>
<div>
Traumas don't go the way you would envision from watching a show.<br />
<a name='more'></a> Some of it's right. People come in grievously hurt, smashed up or poked full of holes, and they get the full court press just like on TV. There's a lot of chaos, a lot of tubes and urgent consultations over CT scans and shouting. <i>Who's got the blood and the tranexamic? I need a bigger chest tube! Someone hand me the iStat! Let x-ray come through, please! Hey, hand me that suction! Okay, I've got two units here! </i>It's all very naturally dramatic. And a lot of the time people make it through my part - the initial stabilization phase. From there they often go to surgery, which for me means shipping them to a different institution since my hospital doesn't have a trauma surgeon. That's one big difference. Another is that people often have long-term physical issues as a result of any major trauma. But usually they live.</div>
<div>
<br /></div>
<div>
Sometimes, though, they die, and no one shows you what that's really like. It's... rough. I'll spare you the gory details of the code on that motorcyclist, of which there are many. Suffice it to say that a lot of us worked very hard on him, and he died anyway, and I had to use a lot of hydrogen peroxide on my shoes that night. </div>
<div>
<br /></div>
<div>
One little snapshot has stuck with me in such a way that I may never forget it. Me, on my way to the surgery changing area to change clothes and scrub the blood off my shoes, passing the man's widow. She was facing mostly away from me, talking to a nurse. She had the sneakers we'd pried off his feet not an hour before - no other personal effects, just the sneakers. She held them casually in one hand while she rubbed her face with the other, as though the shoes still belonged to someone, as though she were delivering them to someone, someone still alive. They were completely pristine. It shocked me down in a deep, unexpectedly fragile place. Why did she <i>have </i>those? He <i>died</i> in those shoes, why would she <i>want</i> them? Why were they so clean when his injuries had been so severe? <i>How could I walk past her like that when I had been unable to save her husband? </i>I turned my face from her grief and loss and kept walking.</div>
<div>
<i><br /></i></div>
<div>
Now I feel like every time I get in the car, all I see is people riding motorcycles without gear on. It's a struggle not to roll my window down and yell at them. <i>Hey! You want to come into the ER all mangled, is that what you want? You want us to have to literally mop your blood off the trauma room floor? You want your family to mourn you in the middle of my department holding your stupid shoes?</i></div>
<div>
<i><br /></i></div>
<div>
I know all my patients will die eventually. I know I'm not God, to hold a person's life and death in my hand. I know medicine has limits. But it doesn't change how hard it is to lose a patient who was literally fine two hours ago. I hate that.</div>
The Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.com1tag:blogger.com,1999:blog-1658844413081032183.post-58926219691624843442018-09-05T08:53:00.000-05:002018-09-05T08:53:11.175-05:00SufferingIt's 6am and I've been up for three hours, the consequence of coming off a long weekend of night shifts. I read for a while, but as often happens to me, eventually I was driven to write. And so here I am.<br />
<br />
My hands are healing, I think, and my feet. In retrospect I've been through this cycle a dozen times before and just didn't recognise it. It matches what my neurologist told me about my disease. It's a cyclic dance, led by demyelination, followed by damage to the axon, the long delicate wire of the nerve cell, as it loses its insulating myelin sheath. I lose some function. Then comes whatever healing the body can muster and some degree of functional improvement - all set against the relentless drumbeat of the disease state itself. So I get worse, and then I get better, sort of. What matters to me now is that I've crossed back over the invisible line that lets me use my right hand. I can write again, so I can do my own paperwork at work. I can hold a glass in my dominant hand without thinking about it. I can put my car in gear without reaching across my body. I can type a bit. I'm definitely not back to normal. I still wear a wrist brace (like <a href="https://smile.amazon.com/RCAI-44DCT-L-R-Dorsal-Carpal-Tunnel/dp/B00RDIZUHA/ref=sr_1_3?rps=1&ie=UTF8&qid=1536154006&sr=8-3&keywords=dorsal+wrist+splint&refinements=p_85%3A2470955011&dpID=41UbLKwpT%252BL&preST=_SX342_QL70_&dpSrc=srch" target="_blank">this one</a>) on the right about half the time since it's very fatiguing for me to control my wrist and fingers simultaneously. I prefer to use a big silly-looking pen that's easier for me to grip. I've switched my mouse to my left hand and don't plan to switch back. And at this point I still can't really do repetitive tasks that require fine motor skills - scissors, suturing, chopping vegetables. But it's so much better than it was.<br />
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Obviously it's going to get worse again eventually.<br />
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I've been thinking lately about suffering, and about God's purposes in allowing His children to suffer. I have found myself crying out to Him this summer in confusion and pain. <i>Why, God? Why this? Why now? Why my right hand, the hand I rely on? Why should I suffer like this?</i> It's a hard question, and a nuanced one. It's different from painfully pouring oneself out to serve others, different from the direct and expected consequences of sin, different again from persecution for my faith. This just... sucks. It sucks every day. And nothing I or anyone else did caused this. I think the temptation is to see suffering as meaningless, just a random consequence of living in a broken, messed-up world, but Christians don't have that philosophical out. We trust and believe that we have a personal God, one who cares for us and is invested in us. So why the suffering?<br />
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Yesterday I sobbed through <a href="https://itunes.apple.com/us/podcast/renewing-your-mind-with-r-c-sproul/id110916650?mt=2&i=1000417833191" target="_blank">a talk</a> given by Joni Eareckson Tada, a lady who is a staunch believer in Jesus, an author, speaker, and artist, and a quadriplegic since the age of 17. I highly recommend that you listen to the talk, although if you're not dealing with personal hardship/ disability it may not resonate with you. She confronts the endless gauntlet of her daily life (you'd better believe that being a sharp mind trapped in a useless body involves suffering) with a matter-of-fact courage that frightens me. She does not spare anyone the harshness of truth. I'll give you an example. For anyone, but especially a quadriplegic, to say, <i>There are better things than walking. There are better things than the use of your hands,</i> is deeply shocking, right? But with reflection I've realised that of course that is true, especially for a Christian. Jesus is better than anything.<br />
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The goodness of God is the truth that sustains a person through even the deepest darkness. I thank her for reminding me of that. Joni Eareckson Tada exemplifies for me the concept of suffering well, something she touches on in that talk. It's hard for me to get my arms all the way around the idea, but I think it's a mixture of day-to-day grit and unswerving, joyful faith in a good God. I don't know how to do it yet like she does (I'll grant that she's had fifty years to learn how to suffer well and I've had, like, two months). But I think most people <i>never</i> learn how. It's just not guaranteed. And I think it's a lofty goal but a worthy one, this idea of suffering well as a Christian. I have this disease. There is no getting rid of it. But to suffer well... if that is my race to run in this life, God grant that I might achieve that.The Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.com0tag:blogger.com,1999:blog-1658844413081032183.post-32948200761684716772018-08-15T21:12:00.000-05:002019-01-28T10:45:44.904-06:00Spoons<div style="-webkit-text-stroke-width: 0px; background-color: transparent; color: black; font-family: Times New Roman; font-size: 16px; font-style: normal; font-variant: normal; font-weight: 400; letter-spacing: normal; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; orphans: 2; text-align: left; text-decoration: none; text-indent: 0px; text-transform: none; white-space: normal; word-spacing: 0px;">
A few weeks ago, my hand cramped solid around a woman's leg while I was trying to put a splint on her, and then went limp for the rest of the shift. Let's talk about spoons.</div>
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In my last post I mentioned that I recently got a lot worse as far as daily symptoms. My legs and feet are definitely weaker than they were, but by far the most life-affecting change has been to my hands. From the end of spring to now I've lost my ability to do most tasks that require fine motor control or forearm strength on my right side - and yes, I am very much right-handed.<br />
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Hopefully you are familiar with <a href="https://butyoudontlooksick.com/articles/written-by-christine/the-spoon-theory/" target="_blank">spoon theory</a>, but if you aren't, here is a brief summary. A girl with lupus was trying to explain to a friend how difficult it is to be chronically ill. To show her, she gave her friend a handful of spoons as a visual aid to represent the units of energy/ function she had for the day. Then they walked through the activities for a day, and the friend had a spoon taken away for each activity she chose to complete. The friend quickly realized she simply didn't have enough spoons, or energy, to accomplish all the very reasonable things she wanted to do. That was the point of the exercise - to illustrate that people with a chronic illness/ disability constantly function at an energy deficit for one reason or another that is out of their control, and that that deficit forces not just tough choices but decreased effectiveness compared to healthy people.</div>
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Having recently firmly crossed over from one camp to the other, I'm feeling this change acutely.</div>
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Normal healthy people have essentially unlimited spoons. Sure, you're not going to climb a mountain and swim the ocean before lunch, but that's not what I'm talking about. For a person without a major disability, your to-do list is mostly limited by time, not energy or function, and every day you complete a whole range of things that you need to do that don't even make it onto your list. <span style="background-color: transparent; color: black; display: inline; float: none; font-family: "times new roman"; font-size: 16px; font-style: normal; font-variant: normal; font-weight: 400; letter-spacing: normal; text-align: left; text-decoration: none; text-indent: 0px; text-transform: none; white-space: normal; word-spacing: 0px;">I can tell you this for certain because up until May or so, this was me. Now I feel like I've gone from unlimited spoons down to maybe twenty-five, at least when it comes to using my dominant hand. Mind you, this is for<i> every task</i>, not just heavy or difficult stuff. So. Brushing my teeth? That's two spoons a day. Makeup is a spoon because of the fine motor control. A shower is a spoon. Writing more than my initials? That's a spoon minimum but usually more like 3-5. Texting costs me a spoon. Using eating utensils costs a couple spoons.</span><br />
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Sewing a laceration? Fifteen spoons easy. Same for splinting and most other procedures, because each of these activities encompasses a bunch of smaller tasks. I found this out the hard way. When I run out of spoons, my hand is completely done for the day, and if I push it, it might be done for two or three days. I found that out the hard way too.<br />
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So after I had used a tape measure to measure my patient's leg, and manipulated the roll of splinting material, and used scissors to cut the tough, thick sheets of fiberglass, and manipulated the roll of material again, and pulled open several packages of ACE wraps, and gotten the fiberglass wet and then rolled it in towels (twice) to get it to activate, and molded it to her leg, and started to wrap the bandages around the fiberglass... I ran out of spoons. My hand stayed in a claw for the rest of the splinting, and after I fled the room and stretched out the cramp, I was left with a limp noodle until the next morning. I've done this twice more since then, each time with a different activity.<br />
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I am gradually, reluctantly learning to count my spoons early in the day, and to ration them. As I mentioned earlier, this means both tough choices and decreased effectiveness - not cooking or doing chores or laundry on a workday, not doing procedures for the most part at work, etc. I've been typing this post a little at a time over a week or so. <span style="background-color: transparent; color: black; display: inline; float: none; font-family: "times new roman"; font-size: 16px; font-style: normal; font-variant: normal; font-weight: 400; letter-spacing: normal; text-align: left; text-decoration: none; text-indent: 0px; text-transform: none; white-space: normal; word-spacing: 0px;">I can compensate for some things by using my left hand, but obviously that hand can't do everything a functional dominant hand could do - and it no longer has unlimited spoons either, and having</span><i style="-webkit-text-stroke-width: 0px; background-color: transparent; color: black; font-family: "times new roman"; font-size: 16px; font-style: italic; font-variant: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: left; text-decoration: none; text-indent: 0px; text-transform: none; white-space: normal; word-spacing: 0px;"> two</i><span style="background-color: transparent; color: black; display: inline; float: none; font-family: "times new roman"; font-size: 16px; font-style: normal; font-variant: normal; font-weight: 400; letter-spacing: normal; text-align: left; text-decoration: none; text-indent: 0px; text-transform: none; white-space: normal; word-spacing: 0px;"> numb useless hands is more than I can handle. </span>It means putting more burden on people around me, which I hate and am not good at. Everyone has been very nice about it, don't get me wrong, but I still feel like as an adult woman in my physical prime I shouldn't need help with basic tasks like writing or using scissors.<br />
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I just had my first physical and occupational therapy appointments and both therapists said that they could help. I hope they're right. I WANT MORE SPOONS.</div>
The Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.com2tag:blogger.com,1999:blog-1658844413081032183.post-63068609237286850492018-08-07T11:14:00.000-05:002018-08-08T01:27:15.310-05:00News<span style="color: black; font-family: inherit;">I thought about being artistically coy in how I would introduce this post, but I can't bring myself to do it. I got some bad news about a month ago and it has changed my life.</span><br />
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<span style="color: black; font-family: inherit;">I was recently diagnosed with</span><span style="font-family: inherit;"> <a href="https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Charcot-Marie-Tooth-Disease-Fact-Sheet" target="_blank">Charcot-Marie-Tooth disease</a>. </span><span style="color: black; font-family: inherit;"> In medical terms, it is a genetic neuromuscular disorder, caused (in my case) by a duplication of one tiny area of chromosome 17. It leads to abnormal nerve structure and thus abnormal nerve signal transmission. Over time, the nerves degrade and die off (this is called neuropathy), taking the muscles with them. It starts in the feet and works its way up the legs, and at some point begins in the hands and works its way up the arms. The rate and degree of progression is different for every affected person.</span><br />
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<span style="color: black; font-family: inherit;">CMT is a progressive disease, and the form I have generally comes on slowly. So it was with me, although I didn't know it. I've been "clumsy" all my life, with weak ankles that are prone to rolling, and weak reflexes. I've always gotten muscle cramps a lot. My feet are always cold. None of that held me back, per se, but there were a series of nuisances to be managed. No stiletto heels. Watch how you walk so you don't sprain an ankle again. Do any workout besides running. But otherwise, it was fine. Then during residency, I started getting intermittent weakness in my feet and toes. The cramps got worse. I started having falls and trouble keeping my balance, especially when I'd been awake for long shifts or wasn't sleeping well. People commented a few times on how my gait looked different, "like it's hard for you to walk." They were right. It felt very hard to walk. I assumed I needed to sleep more and be more diligent about working out, chalked the falls up to residency fatigue, and kept pushing.</span></div>
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<span style="color: black; font-family: inherit;">I know, I know. I'm crazy. No one in their mid twenties should be falling and having trouble walking. I <i>know</i>. But I... just didn't think about it. I was trying to hold it together and finish training, and there was work to be done. So I went to work.</span><br />
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<span style="color: black; font-family: inherit;">Fast forward a few more years. This spring I started tripping over my toes, and I realized I couldn't move them. My right hand began cramping around my pen every time I picked it up. I realized I couldn't feel the bottoms of my feet. Then my knees started to constantly feel like they were giving out, and I finally got scared enough to pursue a possible diagnosis. If you think a doctor can't have denial, think again; despite all of that I honestly thought they were going to tell me it was stress. Instead, two neurologists and $3000 worth of tests later, I was given a diagnosis that explained every troublesome thing I've ever had with this body - and made it clear it is going to get worse. And it has gotten worse; it's gotten a lot worse just in the past couple of months. Apparently that happens sometimes.</span></div>
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<span style="color: black; font-family: inherit;">I will be honest here and admit that I feel inexpressibly sad about it all. I don't know what this will mean for my personal life or my career. It's scary and taxing to try to navigate the sudden drop in my physical ability (a topic to discuss more in a later post). I feel newly, terrifyingly dependent on Jesus, while at the same time I feel so confused that He would allow a time bomb like this to be seeded in my DNA. I trust Him. But I don't understand.</span><br />
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<span style="color: black; font-family: inherit;">I expect the tone of this blog will change significantly from here on out but I don't yet know how. I guess I'll just take it post by post and day by day. But I knew that I couldn't blithely write about the happenings of my life and career while withholding this diagnosis.</span>The Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.com0tag:blogger.com,1999:blog-1658844413081032183.post-40522394522487691392018-05-16T20:13:00.000-05:002019-01-28T10:44:02.297-06:00On Terror"EMS to ED."<br />
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My charge nurse hit the button on the transponder.<br />
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"This is ED, go ahead EMS."<br />
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"ED, this is EMS en route to your facility, emergency status - "<br />
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<span style="background-color: transparent; color: black; display: inline; float: none; font-family: "times new roman"; font-size: 16px; font-style: normal; font-variant: normal; font-weight: 400; letter-spacing: normal; text-align: left; text-decoration: none; text-indent: 0px; text-transform: none; white-space: normal; word-spacing: 0px;">All the staff within hearing distance stopped what we were doing to listen further.</span><br />
<a name='more'></a> I work in a rural, medium size emergency department, so while we see a lot of sick people, on the whole it's fairly unusual for a rig to declare that they are coming in under emergency status. The vast majority of patients that come to the emergency department via ambulance are declared<i> </i>non-emergency status; that doesn't mean they're not sick, but it does mean they're not in the process of dying <i>right now</i>. The distinction matters, because emergency status patients require doctors, nurses, and multiple other staff members (respiratory, radiology, laboratory, etc.) to be present and ready to receive the patient in the room before they even arrive. It's often an all hands on deck situation and the rest of the department is put on hold while we all deal with this critically ill or injured person. It probably only happens a few times a week. The department had a rare quiet moment as we all waited for more information.<br />
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"We have a three year old post drowning. She was underwater about 10 minutes. She does currently have a pulse back after CPR, remains unresponsive and we are bagging her..." The EMT started rattling off vital signs as a mixture of groans and sighs sounded around the nurses' desk. <br />
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The charge nurse jotted down the vitals and when the EMT was finished, said, "Understood. Room 1 on arrival, see you when you get here. ED out."<br />
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<i>Wait, </i>I thought. <i>Wait, wait, wait.</i><br />
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<i>Room 1?! Room 1 is my trauma bay today! </i>I pressed my hands together in my lap and tried to keep my expression neutral as fear sank its claws into my belly.<br />
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<i>Lord, please help me. </i><br />
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<i>You already know this, but...</i><br />
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<i>I have never resuscitated a three year old before.</i><br />
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There's a particular feeling that I get these days when I feel like I'm in way over my head. I get the urge to look around like there's someone who can step in and dig me out of whatever crisis I'm managing, and then I have to remind myself, <i>Zoe, you're not a resident anymore. There's no one to help you out of this. You can do it. Figure it out. </i><br />
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I cannot overstate how scary it is to go through this time and time again. And it doesn't even matter that I (generally) know what I need to do, or at least what I need to do next. It doesn't matter that I've done it all before under supervision. It's still terrifying to be out on my own every time I do something solo for the first time. The first time I set a broken bone without supervision. <span style="background-color: transparent; color: black; display: inline; float: none; font-family: "times new roman"; font-size: 16px; font-style: normal; font-variant: normal; font-weight: 400; letter-spacing: normal; text-align: left; text-decoration: none; text-indent: 0px; text-transform: none; white-space: normal; word-spacing: 0px;">The first time I couldn't stop a seizure. </span>The first time my patient lost their blood pressure, the first time I oversaw chest compressions, my first stroke patient, first major heart attack patient. The first time I walked into a room to see an artery bleeding everywhere and had to stop the bleeding all by myself. The first time I had to decide to intubate a patient - and then intubate them. For the first six months of this job I would lay awake the night before every shift because I was so nervous about what 'firsts' I might greet the next day. I sleep better now, but I still get an uncomfortable adrenaline dump when something new comes in the door.</div>
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That little girl came in seizing and I had to intubate her - the youngest patient I have had to intubate to date. I am proud to say that my team was able to stabilize her and get her on to the nearest children's hospital with minimal delay, and I heard through the grapevine that they were able to wake her up a little while later and she's doing fine. </div>
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My partner, a much more experienced ER doc, congratulated me on the smooth resuscitation afterward. I mentioned how scared I was in the room, and I asked him when that gets better. I thought he would say that after a couple of years the fear fades, once you've cut your new attending teeth on most of the types of high-stakes decisions you will face in this line of work.</div>
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Instead, he laughed. "Wait, is it supposed to get better?" He leaned back in his chair and yelled out of the fishbowl at the other doc working with us that day, another very experienced emergency medicine guy who has worked in a lot of different environments. "Hey, Zoe wants to know does this job get less scary with time?"</div>
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I heard more laughter, then, "What, is it supposed to?"</div>
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"Ha! That's what I said!"</div>
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"Man, if it's meant to get less scary, I'm doing something wrong!" They both laughed again, and the first guy turned back to me.</div>
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"I don't know that it gets less scary, Zoe. You just have a better idea of how to do some of these things as you do it more. But it will always be pretty tough work. People are complicated, you know."</div>
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I sighed. "Yeah, I know."</div>
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The Zoehttp://www.blogger.com/profile/07660347010794673329noreply@blogger.com2