“I keep a jar of nutella by my nightstand. Every night I take a spoonful, then brush my teeth and go to bed.”
“Are you being serious right now?!?”
“Yes!!! It’s soooooo goood!”
“You know I’m going to tell you to stop that, right?”
“I know. But I won’t.”
Sigh.
“What if you just kept the nutella in the kitchen?”
“No.. because then my granddaughter will find it and eat it.”
“Maybe you both shouldn’t be eating it so much?”
“Ahahahaha.. you’re funny Dr. M.”
Hilarious.
“Ok… well, you’re also due for a colonoscopy.”
“Nope, won’t do it.”
“Ok.. and you are due for a pneumonia shot because you’re a smoker.”
“Nope.”
“Well, if you quit smoking, we can negotiate the pneumonia shot…”
“Nice try. But I’m down to just 5 cigarettes a day! So I think that’s great.”
“Could I interest you in a flu shot?”
“That stuff is poison! No way!”
… but cigarettes and nutella… ok. Keep your mouth shut, M.
“So that was just another successful physical. Any questions on that?” I asked my scribe, A.
“How do you do this, day in and day out?”
“Have you heard of Einstein’s misquoted definition of insanity?
Insanity is doing the same thing over and over again and expecting different results.
I’m just clinically insane.”
If he only knew…
As we finished up the note, I kept glancing at my schedule to see when the medical assistant finished rooming my next patient.
Chief complaint: Vomiting
What is taking them so long?
“Sorry Dr. M, she’s having a hard time getting an oxygen level on him. The pulse ox just doesn’t seem to want to cooperate.”
My brow furrowed. Why do we even need an oxygen level on a chief complaint of vomiting?
“I don’t want to run more than my usual 20 minutes late, so let’s just crash that party,” I said to A.
As I walked in to the room, I could see O laying on the exam table in the fetal position, puke bag within arm’s reach.
Was it just me, or did he look like he’d lost 10 lbs since the last time I saw him for a swimmers ear infection?
“Hi O… what’s going on?”
Dry heaves answered in response.
“He’s been vomiting like this since yesterday. He’s been super restless, can’t get comfortable. Really thirsty, but when he tries to drink, it all comes right back up. But he hasn’t had a fever, no diarrhea, no one else at home is sick. I don’t know what’s going on with him,” mom replied, words coming out in a rush.
Deep, chest-heaving breaths filled the silence, mixed with the crinkle of exam room table paper as O kept trying to find a comfortable position. The familiar lacy, mottled skin on his arms and legs compelled me to reach out and feel his hands and feet. Cool to touch. Delayed capillary refill.
“Have you noticed he’s been more thirsty lately, going to the bathroom more often to pee, or even eating a lot more than he used to but still looking like he’s lost weight?”
I turned to look at mom who was nodding, hands wringing in her lap.
“A, will you get someone in here to check his blood sugar?”
As A exited the room, I gently asked O,
“When was the last time you peed? Did you pee this morning?”
“Yes, but only a little.”
His lower lip started to tremble. I watched his face to see if tears would collect – nothing. Cradling his hollowed cheek in my hand, I mentally steeled myself for the hard discussion I was above to have.
I quickly did the rest of my exam – lips and mouth were cracked and dry. Heart rate was very high. Respirations were deep, heavy, but rapid.
What was that called again? Remember to look that up later.
I took special care to make sure he didn’t have any pain when pushing on his right lower abdomen, although a ruptured appendicitis could be painful everywhere. But, his belly was still nice and soft.
My MA rushed in and prepped O’s finger to check his blood sugar.
Pulling up my rolling chair so I could look her straight in the eye, I forced the words out,
“Mom, we’re going to poke O’s finger so we can get a blood sugar level. Based on his exam and what you’ve told me, I’m concerned he might have Type 1 Diabetes.”
I paused to allow her to process my statement, watching as enough tears for both her and O flooded in.
“Dr. M, it’s 457.”
I shut my eyes briefly and took a deep breath.
“It’s too high, isn’t it?” mom asked, not really wanting to hear my answer.
Opening my eyes, I met hers – the same shade of blue-green as O’s, who was now retching into his blue puke bag.
“It is. O is very sick right now. And, I can’t do anything for him here in clinic. He needs a lot of IV fluids, labs and insulin.
This is consistent with a new diagnosis of Type 1 Diabetes, and I just want you to be prepared for when you go to the hospital – they will need to admit him to the ICU, and you will probably be there for a few days. I don’t want you to go home and pack anything, you just need to go straight to the hospital. I will call over there right now so they know to expect you and they will bring him in immediately, no waiting in the waiting room.
I’m going to have someone help you bring him to the car, because right now he’s too weak to walk out by himself.”
Mom nodded, eyes glazed over from the bombshell I just threw her way.
Taking and squeezing her clammy hand in mine, her attention returned back to the room from reeling into the land of “What if’s?”.
“Mom… it’s going to be ok. O’s going to be ok. I just need you to get him to the hospital. Can you do that, or do you want me to call 911?”
“No… I can do it. It’s only 5 minutes away. It’ll be faster if I take him now,” the determination grew in her voice.
“Good. Please get the wheelchair and help them get to their car,” I addressed A, awkwardly observing this life altering moment happen in a matter of seconds from a corner in the room.
After calling report to the hospital, I glanced at the clock. Despite feeling like an eternity, O and mom actually got in and out within 10 minutes.
What a terrible way to run early on my schedule.
A rounded the corner.
“Well, we got him into the car so hopefully they’ll get to the hospital soon. Why can’t you just give him insulin?”
I responded with a smile, considering my answer.
Oh, young padawan. If only it were that easy…
“We always think about diabetes in terms of the high blood sugars. But right now, for O, it’s not the main concern at all. It’s about the acid that’s built up in his blood. Did you see how he was breathing? That’s called Kussmaul respirations, which tells us his pH is likely close to 7, and the body likes it between 7.35 to 7.45.”
Whoa M… where did you dredge that up from? Way to make yourself seem smart!
I pulled up the diabetic ketoacidosis treatment flowchart and proceeded to overwhelm A with a monologue about acids and bases, IV fluids, potassium, dextrose and insulin.
“Wow! I didn’t realize it was that involved!”
A’s excitement over learning something new while being so thoroughly overwhelmed evoked nostalgia. I remembered the ironic joy of realizing how much you don’t know, how much you still need to consume and wanting to soak in every last detail.
The joy of medicine these days was tampered by the frustrations of now learning how to game insurance companies to cover medications and imaging studies for my patients. The irritation of combing through one thousand ICD-10 billing codes to figure out how to code a suspected meniscal tear, but instead settling on “Pain in right knee” after 5 minutes of fruitless searching. Clicking on a checkbox to prove I was providing “Follow up care” to insurance companies every time I responded to a patient email, as if not checking that box would make my response void of care.
With a wistful smile, I stated,
“Well, that’s what they’re going to do for him in the hospital. They get to do all the fun, medicine-y stuff. I’ll just be here to collect the tears when I see O after they discharge him from the hospital, because his life is going to drastically change.”
“But you’re so good at collecting the tears, Dr. M.”
Arching my brow, I regarded A and laughed at his immediately apologetic face.
“It’s only taken a week for you to figure that one out, eh? Don’t worry… you’ll get to see all the tears you want, and then some, if you stick around long enough.”
5:55 pm
The office was quiet on this Friday night, save for the sound of my mouse wheel furiously scrolling through the last of my documents for the week.
I could see the finish line, but there was just one more thing to do.
Logging into the hospital’s electronic medical record, I searched O’s name and jumped into the labs.
pH 6.9. Blood glucose 575. Electrolytes – all wonky.
I allowed myself a small personal victory point for having recognized his diabetic ketoacidosis so quickly, but the guilt of going about it in such a brusque manner cut my celebration short. Before I even realized it, I was dialing mom’s phone number.
What are you doing, M? There’s no way she’s going to answer… she’s in the hospital with her son. You sent her there, remember?
“… Hello?”
“Hi! This is Dr. M from clinic… I just wanted to check in with you. I’m looking at O’s labs from the ER. I’m sure the doctors explained everything, but I just wanted to make sure you didn’t have any questions?”
“Oh, that’s really nice of you. No, everyone’s been really great and they’ve explained everything really well so far.”
“That’s great to hear! … I’m sorry about being so abrupt today. I just wanted him to get to the hospital as quickly as possible.”
Tell-tale sniffles came in response.
“No, I’m glad you did that. I… I didn’t realize how sick he was. Everyone descended on him in the ER when we arrived.
…
Anyway, thank you for checking in. I know it’s late on a Friday night. You should go home.”
“Of course. Well.. I’ll see you when O gets out of the hospital, ok?”
But you’re so good at collecting the tears, Dr. M
I sighed and sat back in my seat.
6:01 p.m.
No matter how much I try to increase my productivity or efficiency, change my work environment or my job, it will always boil down to this.
As soon as I see a hint of a trickle of tears, I immediately rush in to turn the spigot on full blast to fill my overflowing cup.
Maybe the problem is me.
I will always find a way to stay at work longer than I have to. To burn the candle at both ends. To overextend myself emotionally to comfort someone in need.
But isn’t this why you went into medicine, M?
This is what you live for.
The buzz of my phone signaling an incoming text from my husband interrupted my inner monologue.
“Hey, when do you think you’ll get home?”
Husband, family, friends.
This is what you tell others to live for – and yet, they’re the first ones you make wait while you’re out there “saving the world”. Oh… are you getting a little salty from the taste of all that guilt dipped in those buckets of tears?
Don’t worry, M. Your victory today should be able to tide you over til the next time.
Too bad they’re coming fewer and farther between.
***
Photo taken while walking under a waterfall in the Trail of Ten Falls, Silver Falls State Park, OR.
The issue you raise is so nuanced, and I can’t recall the last time I saw it laid out in this fashion. As docs, we always talk of/read about wanting to “help people.” But the deeper question is, “Why do we want to help people?” As you’ve demonstrated, fulfilling this desire to help can scratch a pathological itch – one that leads to straining our psyche and relationships with family and friends.
Yet, you do it. Over and over and over and over. I suspect that, if you didn’t scratch it, the itch might be worse for you than the consequences of scratching it. Of course, the healthiest way to go about it would be to figure out how to scratch it while preserving your psyche and all the other important stuff in your life.
As always, thanks for a thought-provoking post.
I think most of us in medicine suffer from a Savior complex to varying degrees. It brings to mind Don Miguel Ruiz’ quote:
“Humans are addicted to suffering at different levels and to different degrees, and we support each other in maintaining these addictions.”
We all love seeing the struggle – the harder the fall, the greater the redemption story. Hollywood banks on this formula – there’s a reason why people love their reality tv shows although they provide zero value to our lives. It’s probably part of the reason why people read this blog, though I hope I can have people rooting for all of us going through burnout, and not just me.
I was totally with you until you made the outrageous assertion that reality TV adds no value to our lives. In fact, I am submitting your name for consideration as a player on Survivor. That way, you can witness first-hand the sheer awesomeness of the greatest show on television.
LOL.. I don’t think I have enough of a personality disorder to participate, though I appreciate the sentiment that you would love to watch me win that blasted show 🙂
Great clinical save. It is moments like this that help recharge my batteries. After getting burned out reading mammogram after mammogram you can find yourself burning out. It’s those cool cases that come in that get the medical juices flowing.
Indeed! Unfortunately though, the cool cases for me get shuttled out to somewhere else as the clinic/I am ill-equipped to handle the cool.
I am often suprised by my own excitement about someone else’s misfortune. The most “exciting” and “interesting” cases are often neither of those things for the person you are caring for.
I sometimes tell the parents who are there with relatively benign problems that it is good to be bored and boring in a hospital….they dont get it
You did a good job making a diagnosis and having the courage to be honest and upfront with the mom. That is hard to do. It is so much easier to give a wishy washy explanation and leave it to someone else to give the bad news.
P. S. https://www.zedge.net/find/ringtones/Final%20fantasy
Haha.. yesss! You are my hero. I love the midi sounding ones. So many good memories. I actually have FF3 and FF6 on my phone. Just in case I have more time available than playing a 3 minute game of Cube Cube 🙂
Anyway… back to your actual comment – I’ve seen bad news being broken poorly so many times, I would rather have those hard conversations myself knowing that my patients and their families trust me, rather than some random person they met 2 minutes ago. I always tell my patients they don’t want me to find them interesting or exciting – that’s never a good sign.