"I'm allergic to clinic"

Young Dr. Z would proclaim that outpatient medicine "gave me hives"

"The slow pace!  Waiting to get roomed, for prior authorizations, for follow up from your referrals - it drives me insane!"

I ran for inpatient-only practice straight out of graduation and reluctantly turned back when I found my dream teaching position.  My first day of clinic - a hectic Tuesday during which I managed to see three whole patients was terrifying.  "When do you give pneumovax again?  Do I even remember how to do a pap smear?"  I worried my outpatient skills had atrophied beyond saving.

And while the sight of a prior authorization forms do drive me to compulsive and destructive behavior (usually in the form of eating the always-at-hand candy and treats) my stance on clinic has softened in the last decade

Mostly because of Mario.

I first met Mario in the hospital, as one does in any residency program - having heard from my colleagues about this sick frequent flier patient.  An unfortunate combination of two organ systems working against each other meant every other month hospital visits, all of Thanksgiving weekend on my service instead of with his family.

And the two week follow ups as we struggled in vain to keep him healthy.  We carefully reconciled and titrated meds, went over outpatient subspecialist recommendations... but it was a losing battle.

Counts dropped, symptoms worsened and I could see the fight go out of Mario's eyes just before Christmas.  He was at his core, a dedicated Family Man - but it was LEGOs that broke him.  "I could deal with the not working thing, Doc.  I knew it was my job to get healthy.  But if I don't have the strength to play with my kids, I can't do this anymore."

And so we put him in one last time.  Heroic efforts.  Transfer to the regional experts, the Quaternary Referral Center.  "Mario - we're your doctors, and we're not abandoning you.  But you need someone with more firepower than what we have."

And I left him with the line I had used as a hospitalist so many times.  The one I pulled out when I really believed the patient would recover, even when they didn't.

"I know things seem bad right now, but this time next year, it's going to be a bad memory.  That's it.  You can get past this."

Thing is, when you work inpatient only, week on-week off, you almost never get to read the last chapter of the book, much less the sequel.  I never knew whether or not "July of 2016" ended up as an unpleasant time to look back on or something worse.

I did know Mario was a fighter, that he had people to live for, and he would not give up until every option was exhausted.  But in the depths of that very cold winter, my belief wavered.  I wasn't sure that Important Bigname Hospital had what he needed, if we could push back against pathology that had shrugged off every attempt at control.

But the snows melted.  Spring bloomed.

And on a Very Happy Tuesday Afternoon - during the clinic spot I had actually started to look forward to as I mentored a great group of residents through our clinic shenanigans and found my Outpatient skills were not as atrophied as I'd feared - Mario came back.

We had both changed in that time - his changes certainly more stark and physical, but light was back in his eyes.  He looked... like a person.   We as Doctors are so used to seeing our patients in the anonymizing gowns and beds, to see him in a Def Leppard t-shirt and jeans drove home just how much the disease had taken from him.

"I remembered what you said Doc.  That thing about it being a bad memory at some point?  That really kept me going.  So here I am, and I wanted to thank you."

In that moment, I was HIS Doctor.  Not just another person covering the service, admitting or taking over care.  We were a team.

When I became an "Allergy Mom" I learned young children with allergies - even those with complete intolerance can "grow out of" their allergic reactions and can come to enjoy the things they avoided for so long.  Good to know the same can happen with young doctors and the incredibly rich and rewarding world of the clinic.

The worst (and best) phone calls

I dialed the number while sitting in my garage, because it was 5 PM, and that's the time of day when my house "kinda sounds like someone is being murdered over there." (in the words of one hilariously honest resident)

But the background chaos didn't matter.

Nobody answered.  I let it ring for an eternity, as I had been doing.  Nobody was going to answer.

Our patient had days, maybe hours - the list of what could happen to cause them to suddenly decompensate was a mile long, and included "Rupture of known varices in setting of multifactorial coagulopathy"

We knew this was coming, they knew it was coming - the only thing that was uncertain was when their family would arrive. 

A month ago, it was the 20th. A week ago, it was Thursday.  

The barely there, tarnished silver lining to this scenario is that we all had time.  The conversations had taken place - the ones held after hours when the commotion of the wards has quieted and there's that still quality that lends itself to answering hard questions.  The kind that leave you with drying sweat under your white coat once you walk out of the room, the physically palpable emotion still hanging in the air.

So once our patient had made peace with what their diagnosis meant, what things would come to pass despite all our best efforts, everyone planned for It - planned for the change-over to comfort care and DNR once papers were signed and affairs settled.  

But y'all know the one about best laid plans, right?

Wednesday, both the brother and Dad would answer the phone, to answer questions and give updates.  After the no-show on Thursday, the brother would still answer, but we couldn't reach the Dad - who our patient had been so desperate to see for the last month, going through increasingly painful days and treatments to buy them those last weeks.  After Saturday and still nobody arriving, the brother wouldn't answer either.

We as doctors have the opportunity to know someone more intimately than their own family - but in so many other ways, we don't know them at all - we have no clue about missed events, or broken promises - or why family may decide they can't make it to sit vigil over a deathbed.

And so Sunday night I gave the word.  Yes, they were full code.  We had promised not to change their status before family got there.  But the knowledge that it was futile care was spread amongst the night code team - I explained how they could try and do the least harm to the patient at the end.  If any one of the many complications set it, even heroic efforts would not bring them back.

As the sun was just starting to rise Monday morning. The Call Came.  I scrambled up from the couch cushions where sleep had finally come between notes, calls from the ER and refreshing vital signs.

The night intern, who is known for his wit and great big grin... "Uh, it's about, ah... 4502."

Medical Trivia: Sinus pause is a medical condition wherein the sinoatrial node of the heart transiently ceases to generate the electrical impulses that normally stimulate the myocardial tissues to contract and thus the heart to beat.

"I just wanted to make sure that you wanted them to be DNR and comfort measures only. Their Family is here, and they're ok with it."

Our last ditch efforts had worked.  They had even been awake enough to talk for awhile, cracked a few jokes before lapsing back into sleep. 

We could not beat splanchnic dilation in the setting of advanced liver failure.  But we got them time, enough to say goodbye.  

Third Time's the Charm.

He's a cute little goober!

Hokay, another inadvertent hiatus.  But I've been blogging since Geocities (oh, the glory of 90's internet), and I'm not about to let anything as simple as having a second child, moving our entire family cross-country after going through a hurricane, Nick going through Rookie School again, holding down temp jobs and moving twice before settling on my current job keep me down!

So again, with the blog.  And some new clinical context.

As much as I loved Hospitalist work, it was never my end-game.  I wanted to go and put in my years in the front lines of medicine, understand efficiency, disposition and clinical practice outside Academia before coming back to teach.  So when the opportunity came to return to Michigan, the natural inclination was to move to the next phase of my career.  

Actually taking the leap was.... exhilarating. (Terrifying, as the primary breadwinner.)  It seemed like Locums work would be my go-to while I searched for a full-time academic position.  I knew I wanted to teach residents, and hopefully students, and maybe even work at a community type program - something similar to where I trained, not too far out of my wheelhouse.  I had some concerns about my strengths as a clinical educator matching up with a heavily research or academic University based practice.  Oh, and it needed to be relatively close to Nick's job - and our extended families.

Just Kidding.  I was hired almost a year ago.

Of course, finding something that fit such laughably specific standards was going to take quite some time.  Academic positions are more scarce and have far less turnover than Hospitalist jobs, so I found a great Locums company with the plan to work with them for a year or two while I found my dream job....

It would be tough, working in a different city each week, but our family would manage - I was willing to wait.


Happily, I got in contact with the right recruiter and met my new family at St. Joseph Mercy Oakland.  So my days look a little different now.  The census is shorter, rounds are longer, and I even venture into the brave new world of outpatient clinic.  (Definitely more on that in a future post)

But I still hustle home for dinner, the kids occasionally get schlepped over to the hospital to finish up things while Nick is at the firehouse and there are definitely still bodily fluids flying around. 

The hobby changed too.  As much as Roller Derby Saved My Soul, there simply weren't the hours in the day to devote to a highly competitive team sport, with practices usually held right at bedtime.  So I get my bruises and the "You do what, now?" looks from a new source:

Because who doesn't want to run away and join the circus sometimes?