This one chance

This one chance

My morning clinic had been hectic but not very interesting. I felt bad for the student who had been assigned to me – we had not seen any unusual cardiac pathology. Instead, we had heard a long litany by a patient with a recent heart attack who for the life of him could not stop smoking, and been forced to listen to a tirade by an anxious wife who was unhappy with her husband’s nursing home and wanted to take him home for end-of-life care. A large part of that visit had consisted of calming the wife, and hunting down a new oxygen canister to replace the empty one that the nursing home had forgotten to check on when they sent the patient on his way to my appointment.

I sure hoped the next case would offer something more exciting for the student. It was a new consult, an elderly man, wheeled into the office by his wife. When I asked him if he could get out of the wheelchair, he easily acquiesced though I could tell his wife was uneasy. She didn’t say anything, though – it seemed that this was the custom, defer to the husband. He tried to flop onto the exam table, steadying himself with the cane – and almost fell. The student jumped to catch him, eagerly – he was a freshman, in the beginning of his first year, and had not seen a real patient until that day, so to him, catching a patient from a fall was new. The patient grumbled that he was ok, and the wife rolled her eyes.

As we talked further, I couldn’t quite figure out why this patient had been sent to a cardiologist – he had some nonspecific complaints that I could not entirely make sense of, either because he was a bad historian by nature, or had become one after his stroke. His wife tried to supplement the history but due to her language barrier and her general reluctance to take the center stage in the storytelling she was not much help either. In the end, I decided that an objective cardiac test would help alleviate everyone’s concerns, and ordered it. I then spent another half of the visit going over heart-healthy lifestyle, and addressing other, not-heart-related safety and preventive issues that I thought were important for him, such as walking safely, getting physical therapy and doing regular exercises to prevent falling.

After the visit, I helped to wheel the patient back to the waiting room, and saw a little girl jump up from the chair and run over to take the wheelchair away from me. “Our grand-daughter”, the wife said. Oh.

I turned toward the girl: “How old are you?” She proudly extended all the fingers on one hand: “Five!” Somewhat surprised that the little girl had been left all alone in the waiting room, I nevertheless tried to make some conversation.

“So,” I offered somewhat lamely and predictably, “what do you want to be when you grow up?”

“A cop!” came a self-assured and unhesitating response.

The girl then looked at me, pondering, her brunette curly mop shaking, gold earrings glittering, and then offered somewhat less confidently, “And a doctor.” After a moment, the curls bounced again. “Yes, a cop, AND a doctor”.

I smiled. The student laughed. We said our good-byes to the patient and his wife and returned to the exam room to finish the paperwork.

As I stood at the desk, however, I found my attention wandering. I saw other little girls in my mind – myself at age five, uncertain and shy, my little niece at the same age, more confident in what she wants but not sure yet of her place in life. My feet took me back to the waiting room.

“Here,” I offered the ears of my stethoscope to the little girl who was still guiding her grandfather’s wheelchair, “Do you want to hear what your heart sounds like?”

“YESSS!” the enthusiastic reply came quickly.

“Ok, here is your heart – ‘tick-tock, tick-tock’ … and here are your lungs, ‘whoosh-whoosh’ – can you hear it?”

The curls bobbed up and down again as the girl turned to her grandmother, spell-bound: “That was my heart! Gramma, I could hear my heart!”

After I had retrieved my stethoscope from the small hands, the student and I parted the second time and went back to the exam room. While I was trying to make some teaching points about the case, the excited squeals were still very audible from the waiting room, “The doctor! My heart! It went tock-tock! I could hear it!”

The student laughed again. “And just like that, you changed this girl’s career trajectory for life,” he offered, jokingly.

Well. Probably not. But who knows? One chance is all it takes sometimes.

Maybe the little girl will become a doctor. Maybe the man with a heart attack will stop smoking. Maybe the wife of the seriously ill patient will be less distraught, knowing she can call on my help. Maybe the elderly man will not fall at home.

Maybe.

***********

I never got the name of the little girl. I don’t remember the name of her grandfather. By next week, I will not remember the name of the first-year student who spent the day observing my clinic. They will likely not remember my name. I got this one chance with all of them.

One chance. Every day, filled with one-time chances.

That is a lot of maybes.

***********

Self-care tip: Watch for one-time chances in your everyday life. It may make a change – albeit small – in your life or in someone else’s.

Question: Do you recall a time when you took a one-time chance, or missed one? Tell us your story.

 

It’s not my fault

It’s not my fault

The new on-call resident – Jonathan, I think was his name? – was trying to present another admission to me. He was visibly annoyed.

“…so, the ER calls me and says, you have a patient with chest pain, and I say, what kind of chest pain, and they say, oh, we don’t know, but the patient needs to be admitted, and then I go down and try to talk to this guy, and he is just the worst historian in the world and just stares at me, and says I don’t understand him, and…”

I cut through the never-ending sentence. “Let’s just go down and see him together, hm?”

The light was on in the ER urgent room but I couldn’t really see the patient. The gurney had its rails pulled up, and I could make out a small lump breathing heavily under the blanket. We stepped closer and I called out,“Mr Jones? We came to see you, can you come out from under the blanket?”

The top of a knitted cap made an appearance, with two dark eyes peering out from under it. “Mr Jones?” I tried again. “I hear you were having some chest pain? Are you still having any now?”

The eyes got suspicious. “Ahah,” came a noncommittal reply.

“Well, can you tell me more about it?” I persisted.

“I waited until the morning”, was a cryptic response.

“What do you mean, you waited until the morning?”

The resident interrupted. “He was actually here last night and was sent home, and he came back today morning saying he has chest pain.”

I looked at Mr Jones again. It is not uncommon for patients who have no place to be, to complain about chest pain as they know it is a sure way to get admitted. This guy really did look sick, however. After some grumbling, he sat up for an exam. Clearly, he was in decompensated heart failure, and had been for a while. I motioned to Jonathan to step outside the room. “Is there anything about heart failure in the chart?” I asked him. “Yes, he has had heart failure for a while now – methamphetamines,” he added quietly under his breath, “EF, ten percent, but noncompliant with treatment, still meth positive last month though he denies using”. EF stands for ejection fraction – the normal being 60 percent – the lower it is, the weaker the heart muscle. I glanced at the monitor – heart rate at hundred and ten, blood pressure 80 systolic – he really should have been admitted last night. The ER attending had completely missed the heart failure part. I suppose Mr Jones didn’t make it easy.

I tried to get a little more information. “Mr Jones, when you say you waited until the morning, where exactly were you waiting? Did you go home?” The patient was evasive. From the bits and pieces of his broken sentences, it became obvious that he had somehow hid himself on the hospital grounds all night and come back to the emergency room when he thought the shift had changed and he would get a chance with a new physician. I decided not to press him further until he had gotten a little better.

As the day progressed, more wrinkles appeared in Mr Jones’s case. It turned out he had been diagnosed with a lung mass two years earlier and biopsies and surgical follow-up appointments had been scheduled that Mr Jones had not kept. He had not seen a health care provider other than the emergency room for at least couple of years. His heart disease was thought to be related to his drug use – initially, he had admitted heavy methamphetamine and alcohol use that he now denied. Unsurprisingly, his urine drug screen still came back positive.

****

The next day, Jonathan and I went to see our patient again. He was breathing a little better but had an expressionless look that was speaking louder than any words. I decided to press for words.

“Mr Jones, what do you know about your cancer?”

Blank eyes turned toward the wall.

“Well, they said I had one but then that’s the last I heard about it, couple of years ago.”

“Why didn’t you keep your appointments then?”

The eyes blinked rapidly. “Well, I didn’t know I was supposed to keep them, did I? They didn’t tell me what I was supposed to do…” The tail-end of the sentence ebbed away as Mr Jones was feebly trying to come up with a justification. The defense was half-hearted, as if he knew there was really nothing to say, and nothing he said changed anything anyway.

Jonathan at my side was struggling to remain silent. As a young physician, he was taught to help people, and it was frustrating to him that the help had not been accepted. Mr Jones was a veteran – all the healthcare for his cancer would have been free. Now it was too late. For Jonathan, it seemed like a failure, and what young physician likes that?

****

In the end, we were able to stabilize Mr Jones’s heart failure but his cancer was already spread to most of his body and could not be treated. He was no longer able to take care of himself, and was packed off to the nursing home for the rest of his short days.

It had been a good learning case for the residents – not because Mr Jones had presented a medical challenge – but because he had taught the limitations in our communication skills. We had never been able to engage Mr Jones in any meaningful way, and he remained as absent on the day of discharge as he had been on admission.

As an attending physician, I struggled to make sense of it to myself, so I could explain it to my residents. Was it supposed to make sense? Had we failed somehow, or was the outcome already determined before we got involved?

I tried to put myself in Mr Jones’s shoes, knowing for years that he had cancer but putting it out of his mind. Was he sorry now? Or was the current indifferent attitude merely an acceptance of his fate, knowing deep down that he would rather have chosen those carefree years again, living alone in his trailer, drinking, smoking cigarettes and weed, and allowing himself a hit of meth whenever he could spare the money? He had missed countless procedures and surgeries, doctor visits, blood draws, and lectures by the likes of me about his drug habit. Now in the end of these years, the choice was no longer his.

Remembering the vacant stare, I suspect Mr Jones may not have known himself.

****

I told Jonathan that he had done well, and that he should not give up on people. I suspect there will be time for more cynical life lessons later.

 

Self-care tip: Good intentions do not always result in good outcomes. Recognize when your help is not accepted – it is not your fault.

Question: Have you felt helpless in a face of suffering or personal struggle, and found yourself unable to help? Tell us your story.

Doctor, no offense but I don’t want to see you

Doctor, no offense but I don’t want to see you

It was already close to the end of the workday in my clinic but there was still a new consult to see. It was the usual – a recent heart attack with diabetes, metabolic syndrome and hypertension. Pardon me, I meant to say – there was a new patient named Mr Lowry with the above-mentioned medical conditions.

I went through the chart quickly – some of the medications could be further optimized, blood pressure could be better controlled, the weight would have to come down. I asked the patient the usual questions – no, no recent chest pain; yes, he can walk for couple of blocks until his knees start hurting; yes, he quit smoking; no, he has not been able to lose weight. Mr Lowry answered the questions readily enough though he did not offer additional information or ask questions.

I asked him to take off his jacket and get on the exam table for a quick physical. As I leaned closer to help him push the T shirt up to listen to his heart, I could see there was writing on the shirt. I could only make out the word “today” as the shirt was riding up on Mr Lowry’s generously sized belly. “What’s written on the shirt?” I asked, curious. I received the first smile of the visit, and Mr Lowry pulled the shirt down so I could see. I DIDN’T WANT TO BE HERE TODAY, the shirt read. As I puzzled, my patient burst out laughing. “This is my hospital shirt”, he explained. “I wear this to all my doctor visits. My wife knows that it needs to be washed every time I have an appointment”.

The smug joke masked a deeper truth – my patient was trying to set his own narrative for his medical appointments. He didn’t want to be “recent non-ST-elevation MI, diabetes, obesity”. He was “Mr Lowry who doesn’t want to be sick”.

There is something freeing in naming the negative emotion. It is now out there and identified. In regards to Mr Lowry, it made it easier for me to find the motivation for lifestyle change – “you need to take your medications, lose weight, etc – so that you don’t have to see me anymore”.

Over the next day, I kept going back to the shirt. Is it somehow more powerful to elicit a negative emotion rather than positive one? Politicians certainly know that fear moves people to vote more than a desire for a positive change. The generic “you should exercise to be healthy” is less motivating than “you should exercise so that you wouldn’t get a heart attack”. It is especially motivating if the heart attack has already happened once – now the fear has teeth. When I ask my patients what is the most important thing I can do to help them, the answer often comes in negatives: “I don’t want to be short of breath”, “I don’t want to be tired after walking 10 steps”, “I don’t want to be in the hospital”, “I don’t like the hospital food”.

Few weeks ago, Mr Herkel was admitted to my hospital service. He was an epitome of a healthy 53-year old – slim, fit, didn’t smoke, exercised regularly. Part of the reason he had kept himself healthy was his bad genetic lottery – most of the men on his father’s side of the family had already had heart attacks or died by his age. And now, when he had developed chest pain that refused to go away, he anxiously checked himself into the emergency room. The type of chest pain he had was not especially worrisome – but due to the significant family history, we did a thorough workup nevertheless. His careful lifestyle had counteracted his genetics – the tests showed no heart disease. Mr Herkel’s relief was palpable. “No offense, doctor,” were his parting words, “but I sure hope I will never have to see you again!”

As for Mr Lowry, I am waiting for him to come back one day with a different T-shirt. The one that says, I DIDN’T NEED TO BE HERE TODAY.

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Self-care tip: Sometimes, a powerful negative emotion may be a motivation for positive changes in your life. But you have to name the emotion first and evaluate it. Be smart.

Question: Have you had a negative emotion change your life for the better?  Tell us your story.

Blue Corvette and Cowboy Boots

Blue Corvette and Cowboy Boots

Some people love their cars and some people don’t.

I drive a Honda Civic – a perfectly serviceable car. It hasn’t been washed for half a year – after all, there is water restriction in California, or so I tell myself. There is a dent in the back bumper from that time when I tried to parallel park and a post magically appeared behind my car. I haven’t bothered to fix that dent nor the scratches that the car got when I fearlessly drove through a felled tree on the road. It’s not that I don’t love my car. I just love its functionality more than its appearance.

Several years ago, as I was walking to my job at the hospital, I saw a colleague getting out of an electric blue Corvette. The car was beautiful – compact, sleek, sparkling in the sunlight. My colleague happens to be not only a very tall but also a somewhat heavy man, so he had some difficulty getting out of the car – the Corvette was not made for his body habitus. Nevertheless, he looked positively radiant. I asked him later, “Why did you spend so much money on an expensive car that is too small for you and does not have that much functionality?” (perhaps I haven’t mentioned that I am not a very polite person). His answer surprised me. “It makes me happy”, he said. “When I get up in the morning and think about facing the day in front of me, I know there is always a bright spot in the beginning – I get to drive my Corvette to work. And that makes me happy.”

I pondered this. There was no way any blue Corvette was going to make me happy. Even a bright orange Aston Martin couldn’t make me happy. And I like orange. But I had to admit that I could not judge my colleague or somehow downplay his joy over something I didn’t understand. People are different. Happiness is relative, and in the eyes of the perceiver.

Over the years, I have had many conversations with my patients about what makes them happy. I have started looking at it as part of the treatment for their heart disease. People who can name sources of their happiness are usually more motivated to take their medications and to follow the lifestyle advice. Additionally, there is a small secret that the physicians may not tell their patients – and I just exposed it in case any of my patients happen to read this blog – tying the lifestyle advice to the sources of happiness makes it more likely to work. It doesn’t have to be a big thing – more often than not happiness comes in small packages. It can be a father, now less short of breath, able to play catch with his son. It can be a chronically ill patient now able to take an airline trip to see a new grandbaby. It can be singing a solo in church, making a trip to the grocery store, walking around the block.

Just recently, a patient I had not seen for few months, literally skipped into the room for his clinic appointment. “Are you seeing this?” he asked triumphantly, a big smile on his face. Well. Sometimes patients forget that I see dozens of them every day, and expect me to remember everything that was said at their last visit. I searched my brain as I was looking at him. Ah. The cowboy boots. Mr Golnach was wearing beautiful patent-leather ornately decorated boots that might as well have walked down from an expensive store window display. This had been his dream – to get his leg swelling down so he can finally put his beloved cowboy boots on. Clearly now, between better diet and regular medications, his heart failure was compensated well enough where the boots had become a possibility. “Isn’t this great,” he sighed happily. “Now I can die”.

Self-care tip: Find sources of happiness in your life, small and big. Naming them will add quality to your life, and keep you motivated to live better.

Question: Tell us your story about an unexpected source of happiness. 

Sparks of Joy

Sparks of Joy

The emerald green color had faded. The hem was somewhat frayed. The sleeves were a little tight. The old shirt stared at me as I was working my way through the closet and picking out things to give away. I knew there was no point in trying the thing on for the hundredth time – it hadn’t gotten less tight or old with the years. I had really liked the shirt at one time and worn it a lot but it really should have gone to the ‘give-away’ pile years ago.

I tried to figure out why the shirt was still in my closet. I had read about home organization guru Marie Kondo and her approach to cleaning and tidying – so I thought I would try. Kondo maintains that foundationally, we have relationships with our belongings, and we should spend some time figuring out which ones elicit strong feelings in us and which ones do not, so our lives don’t become cluttered. She calls it “sparks of joy”. I closed my eyes and held the old green shirt in my hand. I envisioned myself wearing it. No sparks of joy. Ok then, easy – throw-away pile it is. My hands were strangely reluctant and nudged the shirt back toward the closet. Interesting. I closed my eyes again and ran my fingers over the shirt. Ragged edge, stitching…slightly different stitching. I opened my eyes. There it was. My Mom had mended the shirt when she was visiting me, perhaps 10 years ago.

It’s not like I never see my Mom – I talk to her on Skype all the time, and I see her when I visit my home country every couple of years. We have a good relationship. She sends me things, so there is no need for the old shirt to remind me of her.

When I thought about it further, I realized there was more to it. My Mom, while still in relatively good health, no longer likes long travels. She has told me on more than one occasion that she doesn’t expect to undertake another trans-Atlantic journey from Europe. It has made me strangely sad. I don’t think it will change the frequency of me seeing her. But she will never again go through my closet and give her opinion on the clothes I wear. Or pick oranges from my tree. Or mend another shirt that I like but has loose stitching. Or plant new flowers in my garden.

I miss the thought of my Mom in my house. So, I compensate. I take my iPad to the garden when we Skype so I can show her how my avocado tree has recovered from the frost and how big the rose bush has gotten this year. I call her from the store to ask if I should buy a particular piece of clothing. I hold up the phone if she happens to call me when I am out with my friends so she can say hi (she really hates when I do that).

At the end of the day, I put the green shirt in a different pile in my closet. This is the pile that I keep for my nieces – in case they want to wear anything from there in the future. And I am keeping my own stitching skills alive – so I can offer to mend their clothes when I visit them.

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Self-care tip: Allow for things in your life to have a relationship with you. They don’t replace people but may paint richer shades to your life.

Question: Have you noticed that some things you own have more meaning besides their functionality? Any objects that attach to a special person in your mind? Tell us your story.

Links:

Identity that refused to fade

Identity that refused to fade

“Who is changing this TV channel to cooking shows?” a nurse was asking, exasperation evident in her voice. “Every time I turn around, someone changes it, and I am sick of it.”

The voices from the ICU patient room were audible in the hallway. I stopped to listen before I entered the room.

“But the patient…” – the nursing student couldn’t quite get the word in. “What about the patient?”, the nurse interrupted. “I am sure the patient doesn’t want to watch some boring cooking show; here, I am changing it back to the news.”

I’m a hospital based cardiologist who does a lot of consultations. Today, 88-year old African American Mr Jaafir, very sick all over, including lungs and heart. A ventilator had been breathing for him for about a week and it didn’t look like he would be able to get off any time soon. Still, he was mostly awake; when people asked him questions, he was able to write the answers on the paper – the ventilator kept him from talking. During one of my earlier visits, I had run into his large family at the bedside – a younger stylish wife and several verbose sisters, all of them clearly attached to the patient, and eager to pass on his life stories.

The family had told me what the current nurse Marcy did not know – Mr Jaafir had been a chef, and a famous one at that! I had listened as they told me of his famous dishes – the ones that people traveled distances to sample, and were featured in local newspapers and TV shows. Not only was he well known for his restaurant cooking but his home was a central location for the whole neighborhood. I had also learned that being the center of attention had resulted in an interesting life with several marriages and numerous children and grandchildren.

I told all of that to Marcy.  She knit her eyebrows for a second to think and then chuckled, “So, Mr Jaafir, this is why you have been banging on the bedrails when the channel was changed?” The patient glared. Having been an authority figure to numerous family members and friends all his life, he did not take kindly to the loss of control. The cooking channel stayed on for the rest of the day. And for Marcy, Mr Jaafir now had an identity apart from being a random patient on the ventilator.

Over the next couple of weeks, the family and friends came and went. Mr. Jaafir stayed opinionated – the bedside table was littered with sheets of paper,  his directives with exclamation marks and triple underlines readily visible. However, his strong opinions could not sway his weakened body, and it finally gave up. He knew it before it happened, and his writing changed from “I want to go home” to “let me go”.

I stood at attention with the rest of the staff and his family when his body, covered by the American flag to honor his service to our country, was taken away to the morgue. I had admired the way this man had lived – with a strong sense of self, touching multiple lives on his way, taking care of his family, commanding strong respect in his career. Even more, I admired the way he had died. The formidable sense of self had accomplished a rare feat – retaining his identity while helpless in the ICU. He died as he had lived – strong, surrounded by family, firm in his insistence to choose his own path.

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Self-care tip: You are you. Don’t let people change that. Keep your identity.

Question: Have you felt your identity fading in difficult life situations, such as depression, sickness, and/or stress? Tell us your story.

Dead kids and Mother’s Day 


To all the surviving mothers who celebrated this recent Mother’s Day without their children, lost to mental illness, we dedicate this post.  To the mom’s who have outlived their babies. To the mothers who have watched their boys and girls deteriorate slowly with piece meal pincing bites that brain illness has taken from them until they were gone. To the mommy’s of those who left them fast, at the end of a rope, under a car, at the point of a needle, or in the many bits of brain that a gun blows apart. 

I’m dedicating this post to the mothers who continue to live. Who remember more than the moment of their child’s death. Who celebrated on Mother’s Day the individual of her child that was more than his or her behaviors and emotions. 

This post is for the mothers who remain for us, we who need them still. We need you. Thank you for telling us your story and living with us, among us. For fighting for brain health, for freedom, we thank you. 

To the mothers who survive(d) the death of their children to mental illness, happy belated Mother’s Day. You are amazing to us. 

Today’s question is more of a request: Tell us your story please. 

Or, those of you who know these courageous women, and want to share, please do. We are listening. 

Self care tip: You tell me. How do you (they) do it?

Keep on.