August 24, 2017

Be curious, and listen to their stories

I think if there’s anything that I’ve learned so far in the wards, it’s that you really never know what someone has been through unless you ask.

Case in point: Today, I found out that one of my attendings not only used to be a competitive football player (which I’d found out a couple days ago when I first met him… before I knew he was an attending by the way…), but had also served (and still is serving) as a surgeon in the Air Force for 16 years in Special Operations.  If I remember correctly, apparently, the former makes him one of only about 80 surgeons serving about 350,000 soldiers in the Air Force, while the latter category puts him in a group of even fewer surgeons, who actually travel with the soldiers and do emergency surgeries wherever they are in the field (as opposed to serving in a military base).  He also did his residency at a military hospital where there were no surgical specialty residents, which meant that there were no ENT, orthopedics, neurosurgery, etc residents, so they had to basically learn how to do every single type of surgery, which is awesome (I really really wish we had more of those programs!).  He has been deployed multiple times overseas, and he shared some of what it was like to work in those conditions.  What they had to work with was whatever they could carry on their backs, and he showed me some pictures of what he did in the field with the limited equipment they had (including craniotomies, which is basically cutting open the skull to release pressure!).  We also talked about how there (and even now sometimes), if someone’s about to die, sterilization is not of concern.  They just go at it with whatever they have in the quickest way possible, and sometimes even use things in succession from one patient to the next in times of crises.  It’s kind of shocking to hear/think about now, in our world of antiseptic cleanliness, to not even use a flame to sterilize instruments before use.  But it totally makes sense too, in that context.  “Sure, they might get an infection later, but we’re saving life and limbs out there!  They might get an infection, but at least they’re alive.”  Good point.

In my mind, the term “doctor” has always evoked two images – that of a family/local physician, who treats everyone and everything, and thus essentially is the best primary care/internist there is… or that of a surgeon on the battlefield, with the wounded all around, desperately fighting to save lives.  The latter is what he has lived through, which is amazing.  And he loves it.  I did have to ask, as this is something I have often wondered/felt it would keep haunting me if I attempted to go that route – “How do you deal with having people die in your hands?  Do you ever worry that something you did caused the death of the patient, or caused them even more misery before they die anyway?”  His answer was practical in its simplicity: “Well, if they die, they were going to die anyway.  Or they’ve already died, and we’re trying to resuscitate them.  You can’t do anything worse to them than what is already happening, which is death.”  Well, guess I can’t really argue against that one.

All of this I never would have known if I’d just assumed he was like any other resident/attending when I met him.  Granted, he’s a pretty big/strong guy, and has multiple tattoos, which I guess isn’t the most stereotypical picture of a surgeon, but still.

There are many other cases like that too, but with patients.  While I was at the VA last month for the 2nd half of my IM rotation, I learned about one man’s time in the Navy, where he spent 10 years at sea and lost two wives in the process (he was supposed to spend 4 years at sea and 4 on shore, but he got the short end of the stick and somehow was never given shore duty), and also got cancer, which they think may be secondary to his being on Christmas Island during the atomic bomb testing.  He said they’d been ordered to literally run under the cloud that formed after detonation for as long as they could, which is a pretty crazy breach of human ethics I would think.  But anyway, he also humorously recounted his first trip to Fiji, where 19 year old him was pretty shocked at the sight of the women at the time, who had rushed up to the boats in their native dress, which was topless.

Another veteran told me about how he was fully deaf in one ear and only had 30% hearing left in his other because they blew a cannon right over his head, and that his team of ~32 was able to rescue a whole platoon of about 85 people out alive during the Korean war without losing a single person… but when he got back, the US government lost his record, so he never got any recognition for it.  His story was pretty crazy too – he then ended up smoking and drinking for 42 years, “drunk for the last 14 years”, due to depression from all that happened during his 8 years of service in Korea. Then he had a seizure due to drinking too much on the day before he planned to suicide (by dynamite in a mine shaft, no less) but he says God found him, and he quit both cold turkey and hasn’t been tempted to try again since.  Amazing.  He was also the one who told me “I’m glad it’s you” when I was about to leave after taking his H&P (history and physical exam), and when I stopped and looked at him questioningly, he elaborated with “you’re very thorough, and you seem to really know what you’re doing.”  While I certainly don’t think was an accurate statement for me haha, it was still a very nice sentiment, which I thanked him for.  I ended up having the day off the next day, which is when he got discharged, so I never did get to see him again after rounds or to say bye.  But I hope he healed up and that he continues to do well.

There was another vet, who everyone kept saying was “just crazy/psychotic” because he would talk a lot and seemed fixated on certain ideas.  I went to talk with him, and it does seem like he has anxiety and probably OCD, but I also learned that his PTSD came because he had served in Russia back in the day, when they were on a secret mission I think.  He had been riding around the perimeter with the captain to hear the scout reports, and were on the way back when they found the troops burning in their tents.  He and the Captain rushed in and attempted to save them, but they couldn’t save a single one.  He still remembers it vividly, and feels great guilt over it, but it seems like he hasn’t really told anyone else about it.  I suggested that he find someone to talk to about his experiences to help him through that and his anger issues with his mother, who he clearly loves very much, but gets frustrated by because she no longer treats him like her trusted, beloved son after he blacked out from drinking too much 13 years ago (likely due to his unresolved PTSD and other issues) and never listens to him anymore.  He says he cries after he yells at her and she leaves, and was almost in tears while telling me, but he says he can’t help getting frustrated when they talk regardless.

So many people I think really just need people in their lives to just listen.  No degree is even necessary for that.  Just listening to someone and not judging them can help so much I feel.  But unfortunately in this world, so few people truly have time for that.  Which, I guess, is one of the few blessings, and privileges, we can give/get to our patients as medical students.  The gift of time, as well as an ear to hear, and perhaps even a shoulder to lean/cry on.  Which brings me to my last example – a patient who wasn’t even mine to take care of, but was on our team’s service.

This was a man almost my own age who had been brought in for an overdose on cocaine and probably methamphetamine.  He had been found on the street, yelling at a policeman, and was brought in.  He had multiple lacerations on his arms, and when he had first come in the previous afternoon, the upper level resident I was working with had said “don’t bother” seeing him, I think perhaps because she felt it was a simple case to manage medically and I wouldn’t really learn anything.  However, on rounds the next morning, after some questioning by our attending (during which I found out he’d also apparently re-activated his Hep C), he muttered a few things that I found troubling – that it happened because he “was around people he shouldn’t be around,” that he didn’t want to get treated for Hep C because he had no money since his fiduciary wasn’t giving him his payments so “it’s ok, I’ll just clear it on my own, like last time,” he knew he “shouldn’t be doing this, because every time it happens, I just end up shooting up and having a lot of sex…” and when we then questioned him then how he got the money for the drugs, he said something that sounded like “well, I kinda just you know, sell myself I guess.”  The picture I was getting from this hurt my heart, and so when I found out he was going to get transferred that afternoon to a different service, I made it a point to visit him to try to get to know him a bit more before I had to go to class, hoping I could maybe help him somehow.  At first, he was very reluctant to talk, but when I mentioned his potential transfer and how I might not see him again, I think he realized I cared and at least stopped acting like he wanted me to go away.  I didn’t get all that more out of him, but I did find out that he served in Iraq, and I think he had a very hard time and hasn’t been able to talk to anyone about it.  When asked why he did the drugs, he said “I just don’t want to be me.”  When asked what he meant by that, he just shrugged defeatedly and responded “I don’t know. I just.. hate myself. I don’t want to be me. That’s all.”  I also asked why he was moving states to begin with, as I’d noticed that in his notes, and he said “I was trying to get away from people I shouldn’t be around.  But I’m starting to realize it doesn’t matter, because you can find them anywhere.”  I also tried to advise him to find someone to speak to about all of this, even if it was hard at first, because everything he’s going through is not something that someone can carry alone, and his current trajectory was not good, and he knew it too.

Through this, it was so painfully clear that he wasn’t a drug addict and engaging in these behaviors for the fun of it or even maybe for the physiological high.  He obviously wanted to stop but didn’t know how… because the whole reason he fell into it in the first place was because he was depressed and trying to numb his pain (in fact, his file has a “suicide risk” warning flag that pops up when you open it), and he couldn’t see any way out of his darkness.  I could say a lot here about my now much stronger feelings regarding drug dealers who prey on this type of person, but that’s a rant for another time.  Overall, I just thought his whole story was heartbreaking, and I actually ended up almost breaking down in that room after I said some encouraging words to him that I could tell almost made him cry, and then when I got upstairs to our team room (which was thankfully empty), I just let it all out.  Here was a life that still had so much potential, and yet he was stuck in this dark place all alone, and even we, who are supposed to be health providers, are not able to do what needs to be done to help him, because of the way the system is set up.  He was just going to get discharged after he cleared the drugs, but if there’s no one to talk with him and follow up with him, he’s just going to end up the same way and end up back in the hospital and the cycle will continue, or worse, one day he might overdose and die.  I sincerely hope that is not the case, and that hopefully my words, or someone’s words, will have a good impact and change his life around – perhaps that he will find God as well, like the second vet I mentioned, and be able to see that his life does have worth, meaning, and life.  But regardless, my heart breaks for him and where he is right now, and for everyone who is in a similar situation.  And for all of our vets, who go through so much for our sake’s.

The sense I get from healthcare providers about the VA is often frustration with the system, jadedness about both caregivers and patients, and a kind of resignation, that the patients are all “a certain type.”  And yes, that’s generally true – there is a lot of substance use/abuse in this population, which leads to many of them having heart, lung, and/or kidney issues, and many of course have PTSD or other psychological issues (and amputations).  But really, who can blame them, given what they’ve been through and how (some of them) have been treated when they come back?  It’s a very isolating experience, and for the most part, we as a society are not well-trained in helping people through that.   So don’t be that healthcare person who just writes off a patient because of their addiction or psych issues.  Be the one who listens – the one who learns about the hidden stories.  Everyone has struggles and life experiences that you would never know if you just judge who they seem to be today.  Be curious.  Ask questions.  Spend time.  And just listen, with an open, non-judgmental, and loving heart.  You just might learn something – and in return, you just might end up giving a greater gift of healing to these people than any of the medicines and procedures we’re taught about can reach.


In completely unrelated news, I also found out my Shelf exam score today for my last rotation and… I passed!  I didn’t get high enough to get honors, but honestly, that test was so unexpected and random in the questions asked (very few on cardio, pulm, and renal, and a lot more than expected on trauma, skin, heme/immunology/inflammation and other random facts) that it was the first test I walked out of actually concerned I might have failed, so I’m thankful that I made it :).

August 3, 2017

Ear irrigation and Dix-Hallpike Maneuver and Updates

Today was an interesting day!  Surprisingly mostly because of clinic rather than what’s been going on in the in-patient setting.   So much a bit of background – I’ve switched over to the VA for the month on a different team, and we go to clinic once a week as well to experience what things are like at the outpatient setting.  The first time last week was a little hectic – my preceptor had just come back from a week of vacation and had a lot of catching up to do, so it was a bit of a whirlwind.

Today at clinic though, I actually felt like I was able to participate in the healthcare a bit, which was nice – I am starting to realize I would like to be able to do procedures/work with my hands at least a little with the patients.  Currently in the in-patient setting, I feel like my role has mostly just been talking to people (either patients, other team members, or making phone calls) and looking things up on the internet, but it’s mostly theoretical/medical management, and not as much hands-on.  But today during a routine check-up at the clinic, I got to help out with an ear irrigation due to earwax plugging up of ears leading to decreased hearing (and the patient was actually more comfortable when I did it I think), which was something I’d always heard about but never saw in real life.  Basically, she added drops into one ear (5-10) to soften the wax, then plugged it up with cotton and turned the head over to repeat on the other side.  Then they prepared a spray bottle with lukewarm water, attaching a small, flexible tubing to the end, and then removed the cotton, put the tubing into the ear, and gently spray into the ear until the earwax/dissolved debris runs out (don’t forget to put towels below and use a container to catch the water!).  Also don’t spray too hard, or it’ll 1) be painful for the patient and 2) it’ll spray all over you when it comes back out!

I also finally got to see how to do the Dix-Hallpike maneuver in person!  The latter was pretty exciting to me (even though the move actually turned out to be quite simple) because I’d had a patient with unexplained vertigo last month at the hospital that I thought might have BPPV, but since I didn’t know how to do it and no one on my team had done it before either, I wasn’t sure if I should try it, especially since she was so dizzy at baseline.  But now I know!  Essentially the person sits on the bed, turns their torso to a 45 degree angle, and they are supported down to the bed straight down in that manner (without turning their torso back to a supine position), to see whether they get dizzy.  As an aside, I did end up trying the Epley maneuver on that previous patient to try to improve her symptoms, but it was hard to tell which side was worse for her, and I don’t think it did anything much but make her more dizzy… :\  The one thing that did seem to help though, was talking to her and listening to her – she’d had a lot of really sad things happen to her children/family over the last few months, including deaths, stroke, diagnoses of cancer etc, and so talking with her and praying with her on the last day of her stay I think did much better than anything else we’d done for her during her stay.  I’m grateful I had that opportunity.  May God watch over and comfort that family.

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