Secret Ballot

Families handle dying in such different ways. Our family hasn't had to deal with end of life decisions, so I can't say how we'd do it.  Throughout residency, these family meetings deciding the future of the life of a loved one, have been the most fascinating. The intense emotions, the passionate pleas... I wish I could have a sound recording of them.  This always occurs when there is conflict. It's the same thing every time- 80 something year old mom is in a coma, or has such severe Alzheimers she doesn't communicate anymore.  There are options to be aggressive and prolong life with medicines and machines- or we can let nature take its course.  Ultimately, there seems to always be arguments.  1 sister wants aggressive things, the other wants to let mom go. If only there were written living wills, or something. 

One patient's family this week had an unusual solution.  Their mother- in her 80's, has not been communicative for years.  She's got vitiligo- a condition that makes your skin white.  She's black- so her appearance is startling- like a calico cat- half white, half black - all in spots.  Her mouth is always open- giving her the appearance of a skeleton with it's jaw unhinged. Her eyes are never open. This poor woman needs to die. I can say that easily as a doctor. However, the family wants to keep her alive by any means- well, most of the family.  The arguments have been loud and noticeable by all in unit 43.  The eldest  daughter who's a preacher, is in charge.  She finally decided, enough arguing.  They got the whole family assembled 2 nights ago.  There were 35 people there!  They talked and gave arguments for their positions...and then... they took a secret ballot.  Honestly, they wrote down on pieces of paper wether they thought "mom" should live or die.  No raising hands- you'd be holding grudges with each other for years-  it was all secret.  And the tally-  she lives.

When you step back it's eerie- a secret ballot to decide her fate. Moral of the story-  make sure you know what your loved ones wish for near the end; or you may be the one scribbling "live" or "die" on a piece of paper someday.

Dementia

Have you ever wondered what it really must be like to loose your mind?  To open your eyes and look around, and it all be unfamiliar and new?  I was thinking about that today when we went to see one of our patients with Alzheimer’s. There she sat with her pearls around her neck, and a long gold chain medallion and locket adorning her hospital gown. She was looking at her 2 watches both on her left arm next to her ID bracelet. When we entered she said cheerfully, "I hope you can help me... it seems I don't remember where I'm at or how I got here, but I sure hope I can get home soon." I was surprised she was so up beat, even though she knew her mind was in trouble.  "I'm having a problem with my memory, I just can't understand things" she said, smiling, her glasses half way down her nose like a librarian. She had learned to be clever, adapting to her loss.  When asked "Do you know where you are?" She'd quip, "sure I do, I'm where you are" Is that the grace that accompanies the loss of awareness?  That you also don't know enough to be scared?  I'd think it terrifying, if tomorrow I woke up and didn't know where I was... nothing familiar- the walls, the bed, the people...my mind would whirl trying to recount the last possible memory I DID have.  If it searched and found nothing...what then? Panic? Despair? Yet how happy and childlike Ms. H was.  Unconcerned, if not a bit entertained by all of us.  Although in 5 minutes time, Ms. H will have forgotten me, I don't want to forget her, and her pleasant dementia.  Since I didn't have any camera, I decided to sketch her and those crazy pearls… not as art, but as a reminder.

Puzzle solver

I am back on the hospital side again for work.  This change really only amounts to longer hours and sicker patients. 

It is rare in my job to really come across patients with mystery problems. I'd say 90% of the people who come into the hospital or clinic have names for their problems- they have heart failure, or pneumonia. They know they have gout, or liver failure.  If there is any doubt, usually the ER docs label the patients for us.  It's a shame, because I love solving mysteries.  I think a reason I went into medicine was because I thought I would be putting complex puzzle pieces together to figure stuff out.  This, again, doesn't happen that often.

Yesterday I had such a "puzzle".  This pale 50 year old woman hadn't been to a doctor in years. She was admitted for anemia, with a HGb of 5.5 (VERY LOW).  The work up began, as I thought through reasons and ordered tests.  All day I was absorbed, as tests started coming back very unusual.  I was investigating, and solving riddles, and I was loving it.  One of the abnormalities was gross blood in this patients urine.  Tho she hadn't noticed anything, this was an ominous sign.  Immediately, I ordered a CT scan, to look at her bladder and kidneys. While other tests were indicating she was hemolyzing her blood (chewing up the cells) AS well as having trouble making cells with a bone marrow problem, this blood in the urine couldn't be good.  The CT scan came back late last night.  With no radiologist around to officially read the scan, I took a preliminary read.  I was shocked as I saw what used to be a kidney, now 4 times normal with definite tumor.  Then the liver, studded with cancer, and the lungs full as well. 

My game, of solving puzzles, suddenly wasn't as exciting anymore. I think I had expected discovering the cause of her problems and fixing her; feeling delight in the fact that all the hours spent studying and learning would pay off in helping someone.  It was as if my treasure hunt had turned up, not a treasure, but a trap or a dreadful poison or something harmful.  Yes, I got an answer, but now I had to go sit with this woman, who had assumed she came in to get some transfusions, and tell her that she had a very bad cancer that had already ravaged her whole self. 

I guess, being someone who likes to discover new things, I must be prepared for these situations. If you go turning over stones, you must realize that there are very bad things that live there.  

Following is my patient's actual CT showing the tumor, quite impressive!

Bug in ear

Back in the states, and I  had an experience just now that I didn't realize would happen here.  It is 4 am and I am working a shift in the ER tonight.  We just had a 20something woman come in with something in her ear.  When I came to inquire she said "a bug or worm is in my ear. I was sleeping and woke up feeling something moving"  Part of me thought, yeah right, there can't be a bug in your ear.   So I grabbed the otoscope to look in, and there in full color was a cockroach.  Not a big one, but a cockroach just the same.  I about squirmed when I saw the little creature move, it's antennae twitching.  I calmly told her that there was a bug, and I would be, very quickly taking it out.  Part of me was recoiling. Those who know me, know I detest cockroaches; more than any other insect on earth. My skin was crawling as I sympathized with her, wondering what it must feel like to have it moving around in there.  I put some lidocaine jelly in her ear first, to numb the ear for my planned prodding.  She began to squeal, as this seemed to make the bug angry.  Then the amazing happened- it crawled out...the jelly forcing it into the air. I quickly grabbed it.  Letting the gathering nurses and techs who had been watching see the prize. 

Tajikistan

Pictures are more fun in some ways then boring words. SO I'll post some more. We are almost done with the trip. It's been a blur of activity.  Literally family medicine as a specialty is brand new here in tajikistan. So, our lectures and workshops are helping shape the future of family medicine here.  The system is very "sick".  30-40% of doctors here don't work as physicians, they are taxi drivers and such, because the pay is so poor.  A doctor here makes 15 dollars US a month... that's right only 15 dollars.  They live only by taking extra money from patients.  This has created an impossible system.  If someone comes to the hospital then, they must pay out of pocket the doctor, the nurse, the cleaners that sweep the room, the security people that guard the hospital... every single person demands pay.  The patient must even go supply their own medicines, even in the hospital.  Doctors must also pay bribes to hospital leaders- so dept. chairs demand a portion of earnings, and hospital heads also must get gifts and money.  It is all very corrupt.  The gov't also assigns patients to doctors.  So someone is given approx 1500 people they are to see...then, the rules are that the family doctor must see each of the 1500 patients, at their homes, every three days.  IT is RIDICULOUS.  How can anyone person see 500 people in one day?  For this, again ,corruption ensues, so doctors fake their records...they make up all their visits, and really only get to 4-5 homes a day. This is only the beginning of the problems.  The picture above is of a Foley catheter in the hospital...at least their version of such. 

"When we are dying"

We recently had an Hispanic man on our service. He was 41 and came to the hospital feeling tired and weak, and had a hemoglobin of 4.6.  It's a number that doesn't mean much unless you are familiar with hemoglobin numbers. It's a number for blood.  If the number is below 13 for men, he is anemic. Blood transfusions usually happen under 10.  As you can imagine - 4.6 then is VERY VERY low.  Although he was Hispanic, because the low blood count caused him to be quite pale, it gave a khaki/beige appearance to him. We did a lot of tests; the haunting suspicion was that he had myelodysplastic syndrome, a kind of precursor to leukemia. We did bone marrow biopsies, transfusions, and all sorts of blood tests. We got to the point we were ready to let him go home, needing for him to come back in a month for another bone marrow biopsy.  That's when it hit us - a kind of afterthought - this guy doesn't have insurance. In fact, he's not even a citizen, he's here illegally. How will he even hope to afford his bone marrow biopsy? Let alone treatments for his condition? The morning we discharged him from the hospital we spent some time reconfirming his inability to pay for services. In Spanish he told how he hadn't even been to see a doctor in years because he had no money. He knew something was wrong, and he was getting sick, but also knew he couldn't afford getting better. I can still hear his next words translated by a Spanish speaking resident, "The only reason we come here (the hospital) anyway, is because we think we are dying. Then the money doesn't matter because we will soon be dead" Does that seem right?  He is one of thousands, unable to get help in this land of plenty. He is one of many people sick, knowing something is wrong, who continue to be ill because they cannot pay to get better.  

There is good news for him, this single father of 2. The hematologists who do the bone biopsy are donating it for free. As for future treatment - I am not sure who will pay.

Bleed like stink

"They won't do a biopsy of the mass, those tumors bleed like stink"  This was the 3rd time in a week that I had heard this phrase - "bleed like stink". I try to imagine what this could possibly refer to. Unfortunately this leads to images of blood droplets micronized and floating in the air, being inhaled by the doctors and nurses by someone's bedside. NOT what it means.  Blood doesn't smell, and stinking doesn't seem at all related to bleeding.  The phrase is used to mean 'bleed A LOT', tons and tons...but why the phrase? It's one recognized widely, but who's ever said WHY?  I did some research.  It was tough to find - but here's what I know:

According to the Oxford English dictionary "like stink"  is a pretty generic modifier meaning 'intensely' or 'furiously'.  In other words its an expletive- "If I see a snake, I'm going to run like stink" -  The phrase 'mad as stink' came to be an alternative to saying 'mad as hell' in old English. Somewhere along the way, then, instead of saying bleed like hell - or bleeding intensely, bleed like stink came to be.  Interesting.

Thoughts on death

I wonder if we ever get used to death. I had a patient in the hospital on hospice...which means they are expected to die - they are 'in the process' of dying. From the moment he came in, he was basically unconscious and in no pain. It made me sad that the family wasn't around much, and he was so young- 40's.  Yesterday morning when I was seeing my patients, "rounding" we say,  I came into his dark room.  He was there, on a face mask for oxygen (just a cup around the chin that helps aim the air to the mouth). His eyes were closed, he was breathing hard. His arms were all puffy from too much fluid, so that when you squeezed his hand, you made a dent. If you don't know if they can hear you, I guess it's better to pretend they can, so I spoke out loud. But as I heard my lone voice speaking in this empty room, asking how he was, I felt a little silly.  Can you sense the end? There was nothing different about him at that moment than the other days I visited, but something in the air was charged.  I felt compelled to acknowledge this, "Reggie it's almost over, your suffering is almost done".  I patted his arm one more time and went on with my day. 

2 hours later our whole team came in to see him. Eight of us filed in around the bed, I got ready to speak when I stopped- it was so quiet. The loud harsh breathing noise wasn't there.  His skin still warm, I looked to my attending "I think he's just passed".  We listened for heart sounds, breathing, pupil reactions, etc.  He was gone.

Will I ever comprehend the ceasing of existence? The idea that "He" was there and alive earlier that morning and now "He" does not exist? The essence that was "Reggie" had vanished. Life and death are such opposite entities, it is hard to reconcile my memories of him laughing, speaking, and complaining with the empty mass of flesh lying there. Next came the hardest part of medicine, moving on.  Stopping all thoughts of sadness to go about the next order of business. Though outwardly I had to continue my day, as if pronouncing him dead was on par with listening to the next patient's lungs; inwardly there was an alteration...a slight shift in my brain. Do we get used to death? I hope not, I haven't yet.

Pacemaker deactivation

When you least expect it, some moral dilemma may strike in the wards. I have been taking care of a young 46-year-old man. He, unfortunately, has a very bad heart.  It only pumps at about 20%. This bad pump function causes fluid to back up into his lungs and legs, making anything strenuous just impossible.  He even had a pacemaker and a “shocker” put into his heart. The pacer helps the heart pump and the defibrillator shocks his heart back into life if it stops- which it has done on occasion.  While in the hospital, we've been walking a fine line with him, of getting the extra backed up fluid off of him (we give him medicines to pee it off) while making sure his kidneys don’t stop working from the medicines we give.  There have been multiple specialists involved. He actually could have a better life- and longer life- if he took the initiative to loose about 50 lbs AND if he could tolerate some of the heart medicines.  Unfortunately, he feels that both of these options are impossible for him.  So we kind of limp on, with our meager medical tools- trying to keep him going. 

Yesterday he was to his baseline- his usual semi-short of breath, somewhat fluid overloaded state.  We had reached our medical end and were ready to send him home.  Things changed when he made an unseemly request.  “Doctor, Just turn it off”.  I stopped to clarify, “Mr. R, what are you asking?”  “Just turn the pacemaker off, I have thought about this for a long time. If there is nothing else medical to do, I just want the machine off and let me die” At first I thought he was just angry about being discharged from the hospital, trying to shock us into keeping him longer.  However as the day went on, and more and more doctors became involved it became clear- he was ready to die.

With the Shiavo case fresh in all of our minds, it’s interesting to revisit this area of medicine.  Very often we as doctors are confronted with prolonging and shortening life. It is not unusual for a family, gathered around an aged grandmother on a ventilator, after a stroke has left nothing but a shell, to request that the breathing machine be turned off.  Most of us wouldn’t hesitate to honor the family’s wishes, especially when convinced that the grandmother wished that they never wanted a machine to keep them alive. But when a living, talking, walking, laughing, man says he wants the device keeping him alive to be stopped- what then?  It’s the same scenario – a man-made machine is being withdrawn…without it in place Mr. R wouldn’t still be alive anyway.  So why does it feel so different than the old lady in the ICU?  The difference medically is non-existant, but perceptively the difference is drastic.  One situation feels generous and natural, the other feels like assisted suicide.

We stalled all day today trying to prepare ourselves as doctors, and as humans, to be okay with his request, as the patient was already okay with it.  We had psychologists, ethicists, cardiologists, and palliative care doctors (end of life docs) all come and comment on this unusual request.  All came to the same conclusion. It was okay- he was rational and competent enough to make this decision, and we, as physicians were required to follow through. 

So tomorrow morning, if things continue as planned, the nurse cardiologist in charge of these medical devices will come and turn this pacemaker/defibrillator off. His family will be there, all the doctors will be there, and we, with heavy hearts, will say goodbye.

Too big to leave

We had an unusual problem this week at the hospital. How would you like the problem of being too big to leave the hospital?  That's right, too big, as in obese. One of our 560lb patients was ready to be sent home, we had the special big people van lined up to take her home and everything. They used a special crane thing to get her into a special double wide wheel chair, then down she went to the van and guess what, they said "no, sorry, too big".  Suddenly the nurses were alerting our team that this patient was sitting in her wheel chair in the hallway with no where to go.  What to do? Calls were made to ambulances, fire departments... any place we could find.  As hours passed it became evident she'd have to stay at least another night while we tried to find her a ride home.  I cannot imagine the embarrassment of this for her.

It reminds me of all the other stories I've heard at the hospital about oversized individuals.  We have had patients that have needed special MRI's or CT scans. The weight limit for the machines at our hospital is 400 lbs.  There have been times these tests are so important that we have taken patients to the zoo- they have a special MRI machine for the elephants and other large animals.  Can you imagine- being towed to the zoo to get a test in a machine that elephants lie in?  I also think of the nurses at the hospital, and how it will take 6 and 7 people to help turn or clean some of these special patients. Our heaviest person, a 900lb man had to be taken home once in a semi trailer.

The next day we finally found a company with a very special truck/van that could take our patient home- they needed 900 dollars up front (wisely, for they knew otherwise they wouldn't be paid from this person who had no health insurance).  The hospital forked over the money- and she left.  How she is supposed to get to her follow up appointments with the specialists over the next few weeks is beyond me.  As they wheeled her out, 2 people working hard to push the wheelchair, I wondered at this ironic problem - being too big to leave the hospital!  Sad really.     This picture is not of this patient, but of someone similar (and only about 450)- cropped to protect identity.

Doctor Definition

I have been thinking a bit about the definition of a doctor.  If you look it up in the dictionary under physician you will find “healer”.  This is one of those words that I think we have applied added meaning to.  When I hear healer I think of one who cures, fixes, or rids the body of ailments.  Maybe it’s me that is adding extra meaning- what do you think when you hear healer? In actuality, doctors don’t do this.  What we do is alter the environment. We help design circumstances that lets the body do what it is purposed to do.  When you get an infection, like pneumonia for instance- running fevers, coughing up unmentionable substances, unable to catch your breath –the good ol’ doc writes out a script for an antibiotic.  What does the medicine actually do? It weakens the bug to allow your own body’s bug killers to fight the infection.  When we treat diabetes with insulin or meds, we don’t cure the diabetes. The condition remains; we just supplement the body with insulin- attempting to mimic the natural way it was designed to run.  What about pain medication?  When we injure ourselves and take Tylenol or Motrin- aren’t we really just hiding the pain until our body fixes itself? Ultimately, any medication a doctor gives is attempting to recreate what the original ideal intention was or the medication is altering the environment to allow the natural processes to be effective.  I don’t cure or rid the body of anything. However, here in lies the crux: technically to heal means “to make whole or sound”.  Is designing an environment that permits the body to act naturally, in fact, making something whole? Perhaps it is I who has made the word healer greater than it is, when in actuality a healer is simply guiding the body to wholeness and not curing or fixing. In the end I suppose it doesn’t matter, whether I am a healer or a constructor of circumstance will depend on you and what your definitions are.

Waking

At times it’s helpful for me to think of myself in two parts- me, and my brain.  This is especially true when waking in the morning. When it's much too early to rise, I prefer the shadow me wakes. As "I" turn to look at the clock, I do so gently - like a mother peeking in on her infant child, not wishing to disturb the peaceful sleep. Whatever I do, I don't want to wake my brain. When the brain awakes it does so with the energy and speed of a roller coaster. There is no stopping the processing, no way to slow the eagerness to tackle the day’s foreseen challenges.  While this might seem ideal at the appropriate time of getting up, it is a mighty hassle when the brain decides to wake at 3 am, or worse 30 mins before it's time to get out of bed.  I have tried through the years to find ways to coax my brain back to sleep when it's sleeping time, but have found nothing to slow the electrical impulses once sparked. Thus when "I" awake at odd hours I will continue to move gingerly, lifting only one eyelid to peer at the time, and pray that my other self slumbers on!

College days

They say a picture is worth a thousand words:  My parents say goodbye to my brother after dropping him off at college. 

The weekend was a constant barrage of thoughts and emotions, both witnessed and experienced.  My brother, the last of 4, moved into college this weekend.  Being on a campus again brought back memories from my college days.  I have conflicting feelings when I think about going back and doing college again.  There is part of me that says "thank GOD" all that is over - I would really not like to repeat the last 10 years of school AGAIN.  BUT, there is also a certain part that thinks it would be fun to start again.  Especially if I could know what I know now.  I would make friends with really extreme people of different walks of life, I would possibly pick some other career, and definitely slow down. There seems to be a rush to life once college ends- hurry up and get married, hurry up and get a job, hurry up and start a family. People are always speeding to something.  Colleges are a place to just "be".  People lie on the grass and take naps in mid day, throw Frisbees after supper and talk for hours in the communal bathrooms after brushing their teeth.  When else does that happen in life!  

So, to my brother and all others starting college- enjoy.  If it's possible, open your eyes wider to cement these years into your brain. Even in the sadness of leaving family and loved ones, make that a memory- it's all a part of the experience of this time.

Orchid

I've always heard stories from "the good ol days" of patients actually bringing their doctors corn or a chicken as a thank you.  This habit, I am told, also happens in rural areas where the family doc still is a family friend.  Here in the city, and as a realaitvley new doctor, I thought these stories were more folk tale than truth. Well, it is truth now. 

One of my new patients, a 77 year old man who has survived 4 different cancers, insisted that I accept an orchid and some plums from his garden. This was especially surprising after his accompanying daughter whispered to me "He swore 30 years ago he'd never have a female doc", I guess He had been refered to me by someone who forgot to mention I was a girl. "So that's why he looked so shell shocked the first time I entered the room!" I wispered back.  Knowing that I was going to have to work hard to keep his favor as a female doctor,  I agreed to stop by thier home after work to get these gifts.  I guess it was my first "house call", tho my services offered were more relationship building than doctoring.  In return, I left with a beautiful orchid and some fresh plumbs.  Isn't medicine great!  Ps- he let me take his picture next to the orchid (tho you can't really see the orchid great)

Hospital ghosts

The more time I spend in hospitals the more I start encountering the ghosts of patients treated.  I would guess most doctors, nurses, dieticians, etc would say they experience this phenomenon.  The rooms stay the same, but daily and weekly different souls come to inhabit these rooms.  It becomes their home, with me visiting THEIR space, sometimes 4 and 5 times a day.  It is their ailment, attached to the body and person I visit each day that somehow lingers once they leave.


It is hard to believe that a hospital with 500 beds can have distinct rooms, but each room is like a separate house. I might spend a week visiting 89 year old Irma M in 4314: sitting by her bed, looking out her window at sunrise, standing at her door discussing her with the team as I gaze at her little 80 lb frail body.  When she moves out and Will G; a 30 something with liver failure, yellow even in his eyes, and a belly so full of fluid it's as if someone's shoved an inner tube into his stomach, it becomes disturbing.  Now when I come early in the morning to see Mr. G in 4314 I half expect Irma to poke her head around the curtain declaring some stranger is in her bed.  Her spirit hovers in that room.  If Mr G stays long enough, or I connect with him or with his disease, he too will leave a part of him in 4314.  


You can see the strangeness- day after day, experience after experience I am collecting souls.  As I walk down the hall passing 4302, 4305, 4310, I pass Betty, Vera, that guy with HIV, Ms.C, what's her name that I put a dozen dobhoff's down, etc, etc.  It can become crowded in those rooms.   I wonder if people do this in other professions?  Do teachers have students that haunt their rooms from year to year?  Do Business professionals have memories of clients that linger in their office?  Well, with this new day, I'll have to see who's "moving in", soon to permanently inherit a space in my brain. 

So, just an aside - baby did come at 3 minutes after midnight!

Today one of my patients returning to clinic for follow up said to me, "I would not be on this planet if it weren't for you"  What amazing medical feat had I done?  Did I make a stunning diagnosis in time for a lasting cure?  Did I catch a medical error that would have led to certain demise?  Did I give such glorious advice that her existence had taken on a new life-saving direction?  No.  None of that.

All I did was listen. She had been spiraling out of control, down into some dark depth. I guess I was in the right place at the right time to meet her at that bottom. Interesting that I've spent tens of thousands of dollars on education, even more hours of training and when it comes down to saving lives - I didn't need any of it.

It's funny how fast or quick my interpretations of events can change.  Example:  I woke up this morning and thought to myself "I think my patient who is pregnant will deliver today"  And then in half prayer half thought i wondered -what time will she come in?  10:11 came to mind.  I smiled to myself as if playing a little game. I also had a weird sense that this would be true- enough that i actually put scrubs in my bag on my way to work.   So there i sat in rounds, talking about all the patients we are taking care of.  Suddenly another resident came and whispered "your OB patient is upstairs" I looked at my watch -  Truthfully it was 10:11 exactly.   Feeling lighter than air i went to see my patient, knowing this was from God and a good sign of smooth sailing.  

Now, here i sit, actually in the hospital.  It is 9 pm and it's been a LONG day - still no baby.  What happened to my faith - so self assured this morning, thinking this would be such an easy day?  Was I wrong? Was it a trick? OR is this all still part of the plan?  Was that neat little coincidence just that?  funny how things change-  or more that we attribute goodness to God's plan and negative things to not him- - WHY?  why can't THIS all be OKAY, even when I am tired and just want to go home.  We'll see... and see what she does do AND when the baby will come!!!

I see odd things everyday.

He was an elderly man sitting in his clinic gown with his legs crossed -shoes and socks still on.  What was striking however, was the shimmery pink nail polish in patches on his face. "What doctor referred you to our dermatology clinic?" I asked.  "Aww, no one. I came on my own"  (always a bad sign - if no other doctor is worried about what ever his complaint would be).  "Well then, what's your concern?" He then enters into his story :

"There are these things, maybe like bugs, inside me that lay eggs.  Then in 24 to 36 hours they hatch and come out and crawl all over my face"  I am trying to keep a straight face as I ask, "How many of these things are we talking about?"  "Millions"  "Wow, and what do they look like?"  He scrunches his head to decide how to tell me, hesitates then says "You can't really see them with the naked eye, only with a magnifying glass or microscope"  I am now envisioning this old man in an overstuffed arm chair in his home peering at his arm with a magnifying glass. He continues "I guess they are kind of clear with a brown head" He actually starts drawing something on paper that looks like a cigarette.  "like this, I try to catch em as they burrow into my knuckles" He starts picking at his knuckles as he complains, "the worst tho is I can't sleep, I can feel them crawling all over my face all night."   The poor man had changed all of his sheets and clothes over and over again. He'd fumigated his house. These creatures didn't itch or actually bite him, just crawled and burrowed. "And the nail polish?" I quipped staring at his face which looked like a 3 year old had played make-up with him. "Oh that's too keep them inside, keep them from coming out and crawling. A friend told me it'd help."  

He actually had something dermatologists see often. It's called delusions of parasitosis. As is typical the "bugs" started crawling around 2 weeks after his wife died.  It's often connected to depression.  Interesting way for depression to manifest itself huh? I get spooked just when a hair brushes over me and I think it's a bug- I'll swat my arm or leg and scream.  Can you imagine literally feeling the sensation of hundreds of bugs moving all over your face and arms.  And more alarming, not being able to see them?  I guess I might try putting pink shiny nail polish on me face too : )

From Chambers "At critical moments it is necessary to ask guidance, but it ought to be unnecessary to be saying always - " O God, direct me here, and there."  Of course He will! If our common-sense decisions are not His order, He will press through them and check"  

To me this says - RELAX.  It's silly to go around each day worrying about the decisions we make, and boy do I make a lot of decisions, serious decisions every day.  My common sense/ gut reactions by this time in life should be in tune with what's on the inside.  If not, and I start going in a direction I shouldn't, I'll know.  One way or another GOD will let me know.

Tomorrow is change. New tasks, more hours, less sleep.  Oh well, I'll make it.

Hospital trash

Still working nights.     It's really a whole new world at night.  A new population of people come and inhabit the hospital.  Things happen, that nobody that works in the day even knows about.   I've been amazed at how many people it takes to keep everything looking so nice.   The floors for instance-  they are waxed it seems weekly at 3am.  Does anyone realize that?   The other mind boggling fact I've encountered is the TRASH.  At 2 in the morning, when I walk the halls to go admit a patient I often see these plastic portable dumpsters loaded with bags of trash.   I started thinking about all the trash a hospital must put out each day.  Just one person in "isolation" for a dangerous bug, has 2-3 giant bags of trash a day from all the throw-away gowns and gloves that each person must put on for every encounter.   And there are at least 6 isolation patients in each of the 10 wards here.  When I start calculating all the office trash, surgery trash, ER trash, patient trash -- -little steam is emitted from my ears.   IT's got to be semi-truck fulls!   Every night while most people are sleeping, a line of semi's must pull up to take the thousands of bags of trash.  I should follow it one night just to see - I guess it could be burned?  But it disappears for sure - and the whole process begins again in the morning - trash trash trash.