Month: May 2015

When the Bells Tolled for Me

     Empathy is a big topic in medical education. How do we teach and nurture it in the next generation of doctors? Personally, I’ve noticed that students and residents with personal experiences as a patient often “get it.”
      I’ve had a few personal experiences as a patient and I think it’s helped me gain perspective. Fortunately none of my experiences were life threatening, but one them did leave a big impression.
     In the fall of 1991,  I woke up on one morning with a strange sensation. I had difficulty speaking and drool was intermittently falling from my mouth. I wasn’t in any pain and I remember finding the experience unusual and funny. My father had already left for work and with the situation unclear, my mother sent me to school with an appointment for our family physician later that day. I was happy to go and didn’t want to miss school early in the year. I remember later that morning, despite how my mouth felt, I volunteered to read a section of my social studies text book. I always considered myself an adept reader, but that day I sounded incomprehensible. I even remember the quizzical look on my teacher’s face after my attempt. I quickly realized I would have to hold back my enthusiasm for education for 1 day until my doctor could fix my ailment.
     My family practice doctor was a nice Indian gentleman with silvery grey hair. I remember vividly that his office was also his only examination room. Right next to his large, expensive wooden desk and leather chair, was an examination table, up against a wall lined by his innumerable degrees. It felt like I was being seeing in his home rather than in the sterile exam rooms I’ve grown accustomed to. I don’t recall the details of the visit, except that he had diagnosed me with Bell’s Palsy, given me “steroids,” and a consultation with Neurology. As a teenager, I found this amusing but my parents were extremely concerned. They were so concerned that any run of the mill neurologist wouldn’t do. We had to find someone affiliated with one of the major teaching institutions in New York City.
     We were lucky to get an appointment the following day. After an hour long subway ride, we were in front of a neurologist who was affable, intelligent but also eccentric with hair that only had chance encounters with a comb.The details from this part of the story are foggy. All I really remember is the concern on my father’s face after the doctor advised that we immediately go to the emergency room. For reasons that I don’t recall, my neurologist was concerned about meningitis.
       My inpatient story began like many others in the ER. The most vivid memory had to do with lumbar puncture (LP). My father consented for me, as a pleasant male ER resident explained the procedure and how pain would be minimal and to expect some post procedure headaches. I remember laying on my left side facing a wall 6 inches from my face with my arms clutching my knees close to my chest. With my bottom and back exposed, I felt the warm anesthetic burn its way through my back, while the rest of me shivered in the cold room. My father had to wait outside for what seemed like an eternity. The resident was talkative and friendly but I found it hard to focus on anything else besides my fatiguing arms and lower back. I recall several attempts at him guiding the needle to find the sweet spot. It didn’t hurt but the repeated pressure and prodding of the apparatus was unnerving. After several minutes, the physician proclaimed success and asked me what color did I think the fluid was. I guessed red. To my surprise it was serenely clear.
      I woke up the next morning with a terrible headache and nausea. This was definitely much worse than the actual lumbar puncture. I couldn’t enjoy the view from my window overlooking the East River while the smell of the hospital food made me that much more ill. Despite that, I was happy to see my eccentric neurologist who walked in like the Pied Piper with several medical students in tow. They stood around me, in a semicircle with their shiny white coats, smiles, enthusiasm and words of encouragement. The neurologist demonstrated his cranial nerve exam to the students with my Bell’s palsy playing a central role. The student’s marveled and I felt really special. I wish I could say this was that sentinel moment in my desire to be a physician and medical educator. But honestly, at age 13 although I fancied being a doctor one day, my real priorities in life were baseball cards and video games.
      The days that followed were less about my Bell’s Palsy and more about a nasty pathogen. Although the results of my lumbar puncture were negative, the Varicella Zoster virus (Shingles) reared its ugly DNA. First it was  having a party under the covers of my ear canal which many years later and only in medical school did I learn to call it Ramsay Hunt Syndrome. Soon after, it had found itself on the tip of my tongue in what turned out to be an extremely painful aspect of my illness. I could barely eat for the next several days. To this day, I’m not exactly sure if the steroids that I initially took triggered the Shingles or whether it was the Shingles itself that precipitated the Bells Palsy. Either way, it was a terrible and frustrating combination of events.
     My last distinct memory of this event was the day of my discharge. Like any patient, especially a restless teenager, I couldn’t wait to go home. The night prior, the IV line placed in my ante-cubital fossa gave out and a night float intern haphazardly (after several attempts) placed a new line in my wrist. Probably 6 to 8 hours after that, this too infiltrated and started to cause pain. My family and I rang for assistance. As minutes turned to what seemed like an hour, pain became agony as a huge bleb formed at the site, stretching my skin while likely causing pressure on the carpal tunnel underneath. I squeezed my mother’s hand as hard as I could and squinted my eyes trying to endure the pain. I’m not sure how long I waited, but I remember the catheter being pulled and the immediate relief that came right after. A large fluid filled blister was left behind on my wrist. I was allowed to go home with instructions not to manipulate the blister. Of course one day it did pop, leaving behind exposed underlying tissue that I took care of myself for several days. Luckily it never got infected, but it did leave behind a scar that I still possess today.
    There are a few other tidbits to the conclusion of this story. I parleyed the illness into a new video game system from my parents. The scar on my wrist gave me a tiny bit of “street cred” with my teenage friends. I quickly lost that  “street cred” when I regained my ability and confidence to read out loud in class (4-6 months later).  I missed over a week of school and when I returned, I got a lot of hugs from girls who would otherwise ignore me. And I remember my class portraits that year. I had an ugly crooked smile to match my ugly multicolored shirt. Most importantly, it was a vivid experience that’s given me perspective and a story to share in my life as a physician and medical educator.

“For what are we born if not to aid one another?” 
― Ernest HemingwayFor Whom the Bell Tolls

   

Happy Nurses Week!

     It’s nurses week and it’s very important that we recognize the critical role they play in all facets of healthcare. Personally through the years I’ve had the pleasure of working with amazing nurses in a variety of settings. Here are some examples of what I’ve learned in terms of working with nurses and the important work they do every day.
    Just like most things in medicine, I had to learn how to work with nurses. As a resident, I didn’t have any curriculum on team based multidisciplinary care. I had to learn things on the fly and rather quickly. I spent the majority of my internship in hospital wards where life was extremely fast paced with incredibly complex patients. I took pride in the fact that my senior residents and attendings looked to me as the “eyes and ears” of the team. But soon into internship I felt I needed help and my own sets of extra eyes and ears. Once I recognized that nurses were my partner and not my subordinate, my entire experience and education changed. Nurses were not only executing my ideas, but providing valuable feedback to help troubleshoot issues and allow the formulation of better and more efficient plans. In the busy chaotic world of hospital medicine, where medical mistakes happen far too often, it is imperative that everyone on the team are on the same page. As an intern, I tried to accomplish this by touching base with my patient’s nurses, even if it was for just 15 seconds to get feedback and let them know what I was planning to do. For any future doctors out there reading this, I can’t emphasize enough what a valuable lesson this was.
     After residency, as my career took a direction towards the outpatient world I saw a different but just as vital role that nurses play for our patients. I took a locums tenens solo practice job in a rural part of the country. It was just me, a nurse and an administrative assistant running an entire practice. Since this was a small town, the nurse knew the patients far better than I could’ve ever hoped to. She gave me insight into their lives, struggles and social dynamics that really helped me tailor my medical decision making. She also advocated for me since many of the patients were skeptical of this new doctor fresh out of training. Most incredibly, this nurse was a single mom who had Crohn’s disease and 2 children. She would occasionally come to work during mild flares of her illness in obvious discomfort. She avoided taking days off because she knew I needed her and most importantly her patients needed her. I would suggest that all doctors get to know their nurses on a human level. You will be amazed at the passion with which they play their role in medicine.
     Finally, when my career took a turn towards academics, I worked full-time in a continuity clinic for internal medicine residents. For those that may not know, in a continuity clinic, faculty supervise  interns and residents delivering outpatient care. The patients are usually quite complex, challenging with many social issues. To complicate the matter further, the interns and residents can vary extensively in clinical acumen, effort and general interest in this responsibility. This combination of patient and trainee can be a combustible mix that results in suboptimal care. That is of course if you don’t have an incredible nurse to compensate and account for everything that could possibly go wrong. The nurse I am referring to was critical in many ways for creating a successful educational experience for trainees while delivering excellent care . She would often pick up important issues and clues from patients to relay to the residents and thus make their jobs easier. She would advocate for the trainees if there was a dissatisfied patient. For the trainees that befriended her, she became a confidant and or loving mother like figure. She gave feedback to trainees directly and to me as faculty if something egregious went unnoticed. She had an endless supply of jokes and feel good chocolates to lift their spirits when the days were trying. Her presence was a vital reason why the important educational experience of continuity clinic became something trainees looked forward to rather than avoid. 

     So a special thanks to all the nurses out there in my life, past present and future. You are a driving force in our healthcare system. I’m excited that as we look to innovate and improve our healthcare system, we are all looking to you to be a vital partner in solving some of our biggest problems. Happy Nurses Week!