Nature and Nurture

I love psychology - but it's frightening what we parents can DO to those in our charge!   Last week I got to observe a counseling session.  The session itself was pretty boring, but the background was fascinating.  This 50 year old woman was the eldest child in her family.  When she was 5 or 6 her parents realized that her 4 year old sister was mentally challenged.  Not knowing how to be "fair" to both girls, they decided to just treat them both as if they were mentally handicapped!

For her whole life, this intelligent woman had all of her decisions made for her as if she was incapable of making choices.  A smart woman, avid reader, good at math, etc -she is socially a mess.  She's 50 and has lived 20 years in the same apartment- that was after moving from her parents house. She has never dated, EVER.  Why? because her parents told her not too.  In the session it was fascinating to see that she still can't make decisions, she has been trained to ask her mom and dad (now in their 70's).  She has no depth whatsoever, was never trained to THINK. 

2 lessons then: 1)Just because you are given the capability, I.E. "IQ", if the right environmental cues aren't available you can still be "dumb"ed down.  2)Seeing the consequences, I don't recommend this form of "fairness" in parenting!

First Intubation

Another fun first.  Some would say it’s a little late for this first, as I am 2 months shy of finishing residency.

I was doing an ER shift last Friday the 13th.  I had heard the ambulance tuner go off, and minutes later the paramedics came rushing in with a woman in her 50’s. I heard them saying she’d been found on her couch, unresponsive.  The ER doc looked at her and then said loudly, “this would be a good one for a resident to intubate”

It was the moment of truth.  I could easily stay where I was and pretend I didn’t hear his statement.  Surely someone else would love to practice putting a small tube down a dying woman’s airway? The thing was I had done precisely this for the last 3 years; let others practice this last scary skill of medicine.  I knew it was my time.  I took a deep breath and put on my confidant actor self.

“Dr. Wood, I’d like the practice” I said as I s tepped into the chaotic room with the code in process.

He handed me the laryngoscope and tube and said “Go for it” , then asked, “how many of these have you done?”

I think the 8 nurses busy putting in IV’s, drawing blood and bagging the patient all stopped at once to hear my response.  “Uh, none, this is my first.” I definitely heard some chuckles.

“When you’re ready doctor” the nurse to my left said.  I said okay and they took off the mask that had been pushing air into her. I moved her tongue, but the blade and light in and lifted her chin towards the ceiling. I then hoped the tiny black hole I saw deep down her throat was her wind pipe/trachea.  I grabbed the tube and I heard someone say “It’s a good sign, she has the one eyed wink”  To see better my left eye was scrunched together tightly.  With a little fumbling with the tube, I finally slid it in and prayed I hadn’t picked the wrong hole leading to the stomach.  A few moments later all the confirmatory signs showed I was in.  “Great job” I heard with a small applause.

It wasn’t until I was out of the room I started shaking. Now I'm a doctor, right.  Intubating is some understood right of passage of residency.  And now I can’t think of any other milestones left to cross!

Happiness?

I read an interesting article about happiness this week.  Ever thought about what happiness is?  This article talked about it being more satisfaction than pleasure.  I think society tends to pursue pleasure assuming it will make them happy- when really it's more about being satisfied.  They did this interesting survey-  what would you pick--- You could make $50,000 dollars a year and everyone else you know would make $25,000.  OR  you could make $100,000 dollars a year and everyone else would make $200,000.  What's your choice? 

Most people in the survey chose to make less money- to make $50,000.  Because to them it was more important to be better off than their neighbors than to actually have more income. Interesting huh?  If only we could learn to be satisfied with what we have, without looking outward for a sense of meaning...I think that is when real happiness and/ or even contentedness occurs. 

Denial

In psychology we learn about all of the ways people cope - sublimation, rationalization, reaction formation, etc.  I think the biggest one I see in clinic is denial.

I am working with a surgeon this month who does a lot of breast biopsies and mastectomies.  He'd shown me a mammogram earlier of a woman with certain cancer- the shaggy white edges of the dense mass on the film was ugly looking, as most cancer is.  He purposely scheduled her biopsy for a day I was in clinic. The woman was a spunky young 73 year old who had never had surgery and was on no medications.  She had also missed several years of mamm's because she felt so healthy.

We used the US machine to find the big mass and then using a fancy biopsy gun took several small pieces that looked like 1/2 inch long spaghetti noodles. Unlike breast tissue, these noodles of tissue where very hard and firm like cancer.  The surgeon said nonchalantly "well, we'll let you know in a few days, but this is undoubtedly cancer"

The woman didn't even blink an eye, and even smiled when she said "oh, now doctor, you don't know that! I'm trusting in THE LORD, I have a lot of people praying for me, it's not cancer".

She looked at me for validation, but I couldn't give it. This was cancer and she was displaying denial.  It's not like we were saying "we'll let you know IF...but we'll let you know what KIND" I smiled back trying to convey the seriousness of the world she was getting ready to enter.  I just hope her absolute confidence in God won't shatter when we tell her the pathology results...  because, the results came back today, and it is invasive ductal cancer. 

Intro to Palliative Medicine

This month I am doing something very different, and very rewarding.  Palliative medicine.  Most people get a glassy "what?" look to this term.  Palliative literally means "Relieving or soothing the symptoms of a disease or disorder without effecting a cure"  It is simply end of life care.

Friday was my first day on this service and it was a very full day. I was involved in two cases in the ICU of patients who were being taken off life support.   One 80 year old woman was very alert and awake, but wanted to be off the breathing tube, knowing it meant her ultimate death.  With her 4 grown children and grandchildren around we completed the process of taking the respirator away.  She had a few hours to say goodbye to loved ones before she passed.

During the second pt's extubation there was a stat page overhead to the oncology unit for our team. This was very unusual and unexpected.  The palliative care nurse and I went rushing up to the oncology floor to the room with all the action.  A crowd was gathered outside.  We opened the door, not sure what to expect.  The room was very dark, just a small light from the sink area.  A young woman in her 40's was lying in bed, unconscious. Her children surrounded the bed.  A young blond 6 year old on his 13 year old sister's lap, and both sat clasping mom's right hand.  Another young 9 year old boy sat on the bed grasping the left hand.  Around the bed were about a dozen friends and family.  The room was quit except for small sobs from the kids and the occasional gasping breath from the dying mother.  In an instant I understood she was close to death.

The nurse shuttled us outside to whisper why we were stat paged to this room.  "she's likely to die any minute, and her kids suddenly thought they'd like to have a plaster mold of their mom's hand to keep". The palliative nurse nodded her head and said she had it taken care of, to just giver her a minute.  She rushed off, and I went back in the room.  The space between breaths was lengthening.  The silence would often be pierced with the daughter shouting- "breath mom, c'mon, take another breath".   At one agonizing moment even the dying woman's sister pitched in "You breath now sister, please, breath".    In no time the molds were there, and one by one we had each child take their mother's hand and press it into the mold.  While they did this, we told them how much their mother loved them and had them tell her goodbye.  We stepped out to let them have the last moments alone, and solidified the handprint, something they can have with them always.

Although I was near and involved in 3 people's deaths that first day, it was a very fulfilling day. Traditionally we as doctors have done well with making the process of coming into the world better.  Of course the process of living is always being improved upon...it's high time we look to the end, and attempt to make it as meaningful and comfortable as possible too! 

Generous gifts

In my travels to other countries, I have often been struck by the generosity of people who literally have nothing. I do not think, however, that this is unique to other cultures.  At least, I have recently seen this phenomenon alive here in this very country.  I just didn't realize it would take the expectant life of my newborn to make me aware. 

The patient population I care for is very indigent.  We use this term around the hospital a lot- our "indigent" patients.  The definition of indigent means "lacking food, clothing, and other necessities of life because of poverty; needy; poor; impoverished."  Yep, that's our patients.

I have been surprised several times during these last few weeks of my pregnancy by patients bringing me baby gifts. As I have taken care of them for several years now, I know their social histories.  These are people who've been unable to afford 3 dollar copays on certain medications and who wear the same dirty t-shirts to multiple visits.  Yet, they've shown up with their gifts-  the dollar general labels still on them- sometimes gift wrapped, sometimes still in the plastic bag from the store.  I want to tell them no, to use the money spent for themselves, but there is always such pride and pleasure in their eyes as they hand over the present, that I can't. 

It's overwhelming when you encounter pure generosity. I think these gifts of clothing and baby powder and diaper wipes will be cherished even more than the gifts given with ease.

Toenail nest

You wouldn't guess my podiatry month could get any more exciting than long toenails.  But it has.

This week we had an add-on emergency visit.  It was hard to imagine what a podiatry emergency could possibly be.  An elderly gentlemen in poor health was brought in by his caregiver wife.  He weighed about 350 lbs and had portable oxygen on.  The wife's story was that he had stubbed his toe this morning stumbling upstairs.  She could tell it was oozing a bit, small blood there. She had him sit so she could clean it up.  AS she bent closer to clean it, she was alarmed to see small white wormy things moving around under the nail.

You may have guessed it- he had maggots under his nail.  Our job was to clean these guys out, one by one...ultimately taking off about half the nail to get to them all.

How could this have happened?  The wife explained that with their several cats, they often leave the door open when weather is nice.  This does allow a multitude of flies into the house...which they have grown accustomed to. The older gentleman likes to sleep with his feet exposed from under the covers- creating the perfect egg laying spot for a pregnant fly.

The wife understandably was a bit hysterical at her find.  I felt like being hysterical assisting in plucking out the maggots. 

In case you needed a reason not to let flies in your house-  beware the toenails!!

P.S= was going to post a maggot pic, but just looking up the images was making me sick....will spare everyone