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.

Violence and Originality for friendship

Guest Post!

…keep reading…

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Learning new ideas and concepts releases Dopamine, the “feel good” neurotransmitter/messenger.  I find this theory consistent with my personal experience as I am studying for the boards.  The new concepts, when I grasp them and link them to things I already know, do seem to bring a tiny packet of fell goodness.  So, as I study, i really try to capitalize on this mechanism of feel-goodness.  Maybe I can get addicted to learning.  That would be a great addiction.  I think in some ways, I already am.

Using Dopamine in enhancing our everyday life and getting addicted on life:  Creative expressions can cause release of Dopamine – proven by both science and by our everyday observations of living our life.

Gustave Flaubert, of Madame Bovary, famously said:

Be regular and orderly in your life that you may be violent and original in your work.

To me, this fits.  I find I don’t need to lead a wild and dangerous life.  I don’t need external thrills.  I get my Dopamine from being able to be violent and original in my thoughts and ideas – Quite the thrill.  The regularity and order I try to effect gives me the time and space to be just that – violent and original.

The most cutting truths live in works where the artist is violent and original.    Flaubert, of Madame Bovary, said, “be regular and orderly in your life so that you may be violent and original in your work. “. He is fiercely unapologetic in the way he worked.  I like that.  Be violent and original in one’s work, all the while freeing one’s mind to achieve that end by being regular, mundane, and orderly in one’s life.  The creative juices that thusly pulsates in the artist’s veins more than makes up for the seemingly boring and orderly exterior.

Questions:  What role has learning played in your “feel good” self?  What helps you be violent and original in a way that is friendly to Me?  How do you channel your ferocity in the most friendly way?  How has the boredom otherwise affected your quality of life?  Please comment and tell us your story.

Self-Care Tip:   Be violent and original in a way that is friendly to Me

 

Dr. Chin Tang is in his last year of psychiatry residency training, on his way to Fellowship in psychopharmacology through University of California, Irvine.  He is happily married with much adored children.

Dr. Tang says he likes being my friend because in so doing, he is more “emancipated to be as weird and eccentric” as he is, by nature, meant to be.  Dr. Tang really knows how to make a girl feel great.  Thank you, Dr. Tang! 🙂  Keep on.

Remember, You Are Free, Even When You Accept Help.

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In becoming a friend to yourself, we all use tools; a hoe, a shovel, a bottle of medications, friends and lots of floss.  Not all in the same moment or we might get hurt.  None of the tools we use are meant to been seen, when looked at, alone as a weapon to box us up.  They are each in turn just a tool to be used to improve our ability to be friendly with ourselves.  Don’t get paranoid.

This is important to remember, the more effective the tool becomes.  We build suspicions when things work that well, like ladders in case we need them.  But if we find ourselves miming walls that no one else can see, it really is just about Me.  The walls, the box, the perception of being defined too easily are coming from Me.

If you’ve ever heard about the biopsychosocial model, you may have experienced this sensation.  Each paradigm introduced looks more and more like brick and mortar, and you find yourself acting out the runaway-bride gig.  You are not that special, nor Me.  We are a construction of unique complexity, each of us individual and undefinable.  However, none of us are so special that we can’t use the tools.  None of us are so special that we can be captured; an exotic bird never before seen.  We are in fact too commonplace in our inability to be boxed, shut up and drawn in.    Let that twist your thoughts.

In the biopsychosocial model we use the paradigms as given to us through biology, psychology and sociology to improve our insight and what ever we hope to accomplish thereafter.  It’s a collection of tools.

When a patient comes to see me, looking for help, sometimes they apperceive the tools.  They become distorted towering constructs.  The biopsychosocial model looks like mechanisms designed to take away freedom rather than improve access to freedom.  It is a lot of unknown to be dosed with and it is a natural response.  But the biopsychosocial model is rather a collection of highly effective, (even suspiciously effective,) ways to improve brain disease.

Self-Care Tip:  Remember, you are free, even when you accept help.

Questions:  When have you perceived that you were being boxed in by the “help” coming your way?  How did you reclaim your sense freedom?  How did you manage to still get help?  Please tell us your story. 

Insight Isn’t Worth Much For Self-Care… Or Is It?

Autumn Red peach.

Image via Wikipedia

Much of self-care is about taking accountability for our choices.  Choices come in deliberately – “Oh my!  I’m old already!  It’s time to have a baby!”  Or not deliberately – “Oh my!   He’s hot!  Whoops!  I’m having a baby!”  Both choices brought a baby.  Both choices accountable by Me.

In interpersonal exchanges this is ever in debate.  From parenting to being parented, from spouses to friendship and all up and down the Mississippi river – the martyrs stake rarely collects dust.

That baby keeps her awake and she can never sleep with her husband any more or else no one gets any sleep.

That’s a lot of responsibility to put on those tiny infant shoulders.  Don’t you think?

Mom just runs my life!  I have things to do but every weekend she expects me to be by her side!

Mom may run your life but you are choosing for her to do it if that is true.

The scenes could continue on our imaginary screen, but our own are enough to keep us busy.  We don’t need others from others to get the point.  But insight only takes us so far.  Sometimes I get all grumpy and say, “Insight isn’t worth much.”  Because, we all know that we don’t choose many of our emotions.  We are learning here at FrientoYourself.com also that we don’t choose many of our behaviors.  Insight sits in us like a stone fruit.  Eat it up or don’t, eventually all we have left is a stone if we don’t have the biology to work with it.

Self-Care Tips in a stone fruit:  To take care of ourselves, to take accountability for our choices, to use our insight for more than a midmorning snack fruit – we must have the working body to turn insight into production.  One stone fruit can germinate and grow.

Question:  What relationship does insight have in your self-care?  What limitations does it have in your self-care?  please tell us your story.

Run Away Before You Self-Destruct – Keep Yourself Safe

Run Away Before You Self-Destruct – Keep Yourself Safe

This is a slight remake from 7/25/10. Hugs to all.

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When you feel the pull to do something that isn’t good for you, turn away from it. Do something that you can stand doing at the moment that won’t make you hate yourself now or later.

In the evenings, when the kids are just in bed, the backlash of the day seems to have a few last flicks. Despite the anticipated quiet, my shoulders are tight. Dusk, when the land meets the sky, is when I feel like eating …chocolate specifically.

I purposefully don’t bring it home, except the darkest chocolate sold with over 75% cacao for this very reason. It’s so dark, it’s practically bark.

Home is my safe place and I need to know that it is as safe as possible, even from me. I used to bring treats home that were to be eaten in moderation, but I found that when the monster in me crept out. I’d board myself up in the pantry and polish it off. That would turn me to self-loathing. It was a cycle. I got tired of being my enemy and knowing what was coming next.

Now, I choose to simply go out for my chocolate. I eat what I want when I’m out, when I’m less likely to eat myself into despair. Now, when I’m home, I can pick a different fight rather than fighting the urge to closet eat. Home is a little more safe for me.

Tonight, the kids went to bed ok, but I still took my turn around the fridge and pantry, even though I knew there was nothing, absolutely nothing, I’d want to eat in my house. I am in danger now of developing something of a ritual in this rummage around the kitchen. The good thing is that when I do make the turn, it leads me to the thought of just going to my bike and riding. Tonight, after a 30 minute spin, while watching the last 1/2 of the première to Glee, I am good again. I’m thinking about the muscles in my legs and the way my body doesn’t walk as heavy as it used to and I feel good about myself. Just like that, I feel a little less self-loathing. I feel more safe.

Self Care tip #1 – Run away before you self destruct. Be a friend to yourself.

Questions: Have you found a safe place? What is keeping your home safe for you? Please tell us your story.

Gathering Friend to Yourself Blog-Post References:
Choosing Safety:
  • basics on Weight Management 2011/06/25
  • Trusting our Clinician, or Not 2011/05/17
  • Self-Care Works You, Pushes You, Tires You Out Until You Are Happily Spent On Your Friend – You 2011/04/25
  • Participate – Work as Part of A Team With Your Medical Providers 2011/04/12
  • Choosing Connections – Take The Good and Take Care of Yourself 2011/04/04
  • Check Your Read. Even When You Feel Shame, Bullied and Herded, You Are Free. 2011/03/26
  • Living Where We Feel Safe is Part of Self-Care 2011/03/20
  • Afraid of Meds 2010/09/19
  • Get in Someone’s Space 2010/09/08
  • Run Away Before You Self-Destruct – Keep Yourself Safe 2010/07/25
Self-Loathing:
  • Number One Reason For Relapse In Mental Illness 2011/04/07
  • So Many Choices, So Little Time …For Self-Care 2011/03/05
  • Say, “I Can’t Control This” When You Can’t 2011/01/31
  • Emotions: The Physical Gift We Can Name 2011/01/06
  • Escape Self-Loathing 2010/10/29
Breaking Negative Cycles:
  • Loving Me without ambivalence – Perfectionism v. Passive Surrender 2011/05/28
  • You Can’t Barter With It. Sleep. 2010/12/03
  • Regardless The Reasons Not To, Go Get Your Sleep 2010/11/22
  • Choose, Gladly, Using Resources 2010/10/13
  • Sleep Hygiene – my version 2010/08/29
  • Pay a dollar 2010/07/29

Become a Better Friend To Yourself In and With Your Culture

"Energy Crisis!" ...

Image by Toban Black via Flickr

A barrier to getting friendly with ourselves might be our culture.  The inverse of course could also be true.  ‘Takes culture to design the flavor of our homes and habits, our communities and the energy between us and them.  Think, TV in the bedroom, alcohol tasters offered to children, books or the absence of books on the floor and shelves.  Think religion and diet, family meals or take-out.  The way we deal with shame.  Culture is a gate-keeper for many of us.

We could call our culture, the way we live together at home, the balance between each family member and the flavor of emotions there.  Culture might be layered, wrapping us from one balance of energy into another into another creating our own galaxy between each point of light.  In any room, if we look we can find culture.  In any space outside, there is a flavor telling us how to maintain the balance between me and thee.

I don’t know if sociologists look at culture this way yet, but I hope they will.  With all that observing, data gathered and surmising, I hope they study how the individual can be a better friend to herself in “this” culture.  And then I hope they tell us.

Becoming an active designer of your culture is not always easy.  But it is friendly.

Questions:  How has your culture introduced you to your friend, “Me?”  How have you been able to develop a more friendly culture for Me to live in and grow in?  What’s still keeping you?  Please tell me your story.