Tag: medicine

Home Visit

~ karuna ~ Leave a comment

[This writing was from late February/early March 2020. This was my last home visit before the pandemic hit my city.]

I rushed from a busy ward floor of the hospital to my car to drive to go meet Ms. Bee for a home visit. Her rose colored wooden house with peeling paint surrounded by overgrowing vines and grasses appeared to rise up from the earth organically. It felt out of place on the side of a very busy four-lane thoroughfare of our city and surrounded by newly built, imposing condo buildings that lack the character and charm of her small dwelling. Her house was like a lush desert island in a sea of concrete. “My mail box has been knocked over so many times by drunk drivers. I can’t even count them anymore! One time it got dragged all the way to the corner store,” she recalled with genuine amusement.  

We met in her living room of her home. She sat in her burgundy recliner that seemed to envelop her tiny, bony body, just like her large knit sweater seemed poised to swallow her up at any moment. The moss green carpet beneath our feet felt like an earthy mat. Her medications lined up on the table next to her large recliner gave the impression that Ms. Bee doesn’t move much from her perch. She and her house felt like steady old relics in a city of non-stop movement, expansive growth. Time seemed to slow down a bit inside her little house. There was nowhere to be and nothing left to do other than sit and connect.  

Talking with Ms. Bee was like stepping back in time. When asked if she had any life advice or lessons she’d like to share with young people today, she spoke of her work as an orthodontist’s assistant. You can learn a lot from people’s mouths and learning when to keep yours shut. She also spoke of her childhood picking cotton on her family’s farm and on farms out west where her and her siblings worked with her parents to earn money in the late 1920s and early 1930s. Picking 350 pounds of cotton a day is an unbeatable teacher. She recalled her family’s covered wagon, her father finding a shade tree every summer under which he’d sell the family’s watermelon crop, and the corn they grew for her family of 15 to eat.

Was this modern-day home visit with Ms. Bee a little glimpse into the practice of medicine of yesteryear? Connections were made at home, and a physician was able to assess a patient as a located, contextual, relational human—not as a member of a revolving cast of characters participating in the drama of the contemporary clinic. Similar to how doctors used to visit her family farm when one of her 12 siblings became ill, I met her in her environment, and for that reason, I feel like I learned a great deal about who Ms. Bee is. Seeing where she lives and how she lives painted a three-dimensional picture in full relief of what it meant for Ms. Bee to take care of herself. Her home environment provided me with a glimpse into what made Ms. Bee more than any other elderly woman with a handful of common chronic health conditions; I saw her as a full person rooted deep into the land on which she lives, the same sprawling piece of land on which she was born 99 years ago.

a struggle in 55 words

~ karuna ~ Leave a comment

Charcot foot and weeping ulcerative wounds dragging on the bare ground.

He wanted more time, more options, more consultations with vascular specialists.

A below-the-knee amputation, deferred.

He needed a wheelchair so he could leave the hospital. No one could find him funding for one… for days. Days! Social workers, nurses, doctors, students scrambling to help.

Memory

~ karuna ~ Leave a comment

COVID-19 is in our city now, and our medical student clinical duties are cancelled. I left the hospital early today and saw it as a great opportunity to take time to teach myself about the novel coronavirus that is infecting people around the world. I also saw this (sorta unfortunately unexpected) long weekend as a chance to refresh myself– get centered again after the slog of my school’s women’s health rotation which felt interminable and soul-crushing and rife with examples of social injustice for poor, immigrant, non-English speaking women of color. But ya know, life is unpredictable. Nothing is in our control. My weekend is no longer fully mine.

My mom needs help, so say my three aunts who talk with her the most out of anyone in my family aside from me. She had surgery and is recovering at home– alone. An aunt is there supporting her today, and they all wanted to talk to me today because they’re concerned about her memory (i.e., they think she’s demented and specifically they believe she has Alzheimer’s dementia). I’d agree with them that there’s reason to be concerned about her memory. Her and I have been talking about her memory troubles for years now. The trouble seems to wax and wane with a slow, steady overall decline over the past 5 years. What they don’t know– possibly because my mom hides it so well– is that my mom’s memory issues probably don’t simply spring from some underlying neurodegenerative process like one of the (very many) different kinds of dementias; her memory is also impacted because she is seriously, chronically depressed. I know that her chronically depressed and anxious mental state and her chronic, under-treated sleep apnea for which she uses a CPAP machine inconsistently and her lack of exercise and her poor diet and her lack of hobbies/interests and her lack of cognitive stimulation other than her TV all contribute to her cognitive and memory abilities. She isn’t simply demented. At least, this is what I believe given what I know about my mom right now.

Truly, my mom needs neuropsychologic evaluation. I think the only way we can have that happen is if she comes to visit me here in the city where I’m in school so I can take her to a clinic with me and we can get her evaluated together. How am I– someone not trained thoroughly in neurological/psychological evaluation– supposed to discriminate between Mild Cognitive Impairment (MCI) vs early Alzheimer’s vs some other kind of dementia with amnesic components? To me as a learner, they all kinda look the same right now.

I’ll be going home to be with her for a few days. To make matters more complicated, I don’t even know if I should be spending time with her right now, given my extended time spent in hospitals and clinics for the past weeks while on rotation. But what can I do? When I called her today to see if she’d be ok with me coming home to visit her this weekend and make sure she’s taking her meds and comfortably recovering, she cried. I heard the loneliness and the anxiety and relief in her voice when she said that she’d love to have me at home. Virus or no virus.

What a sacred and intense time illness is. Our lives are literally in each other’s hands. What are we other than our care, our effort, our vows to one another and to ourselves? If this viral outbreak and my mom’s declining health teach me anything, it is that.

To DNR or not to DNR…

~ karuna ~ Leave a comment

I wrote the following reflection at the end of my palliative care rotation in December. It was in response to a clerkship essay assignment in which I wrote about the value of having a Do Not Resuscitate (DNR) order in place for terminally ill cancer patients.

On second thought, I can see the value of a full code status order when living with terminal illness: peace of mind, a glimmer of hope, and preserving the “will” to live for the patient. Being full code means someone else— likely the MPOA but also maybe the entire family— will have to decide when it’s time for their family member to die; in some way, the patient is abdicating their individual choice regarding how and when they die and deferring it to others.

Bizarre but somehow comforting, I’d assume. Full code might mean valuing not giving up in the fight, collective decision making, and having a strong warrior spirit throughout illness. It might signal to the family that their loved one is unwilling to leave them or give up on them.

But could a DNR be something that seems scary and “wrong” simply due to lack of education? What if their ideas of DNR are simply incomplete and/or skewed by misperception? What if they knew a DNR could be a family decision *before* crisis strikes? What if the grief of dying could be dealt with early and not left to the symbolic gesture of love that full code status affords?

A false dichotomy

~ karuna ~ Leave a comment

I find it personally fascinating to see how the very simplest of human tendencies comes out in the crucible that is the emergency department (and perhaps more broadly in the crucible that is the hospital). As humans we sort ourselves into “us” and the “them” in many ways, but perhaps the most insidious manifestation of this is in situations in the emergency department. Troubling is our capacity– yes, our collective capacities– to reinforce that we, the members of care teams at the hospital, are different from those who present to the hospital in fragile, vulnerable, troubling, decrepit, annoying, boring, and/or disgusting states. Patients can easily become the “them” to our “us.” Why do we do this? Maybe in some basic instinctual attempt to assert control and organization over what can be a chaotic and unpredictable environment. Or maybe in some attempt to make the working conditions in the ED (i.e., the pressure, stress, or fatigue) feel more bearable by focusing on something other than the reality of hard work. Or maybe to make one’s self feel better about their own perceived deficits or displeasure. Or maybe because we see something in a patient we don’t like about ourselves or someone we know. Or maybe out of sheer boredom. Either way, those that belong to group Them can easily become a point of fascination, revulsion, or apathy for those in group Us. Not only are “they” bare in body, mind, and (one could argue) spirit in front of “us” in the ED– without much ability to hide, without much privacy in tact– but “they” also become something of a spectacle for “us” to laugh about or analyze or judge or doubt. “They” are different than “us,” and in so far as they are not us, they become less than us. In a quick slip of the mind, they become less than fully human.

We can shelter ourselves inside a bubble of self-importance, of clinical distance from “them,” but ultimately, “they” are as much us as we are. They are us. We are as much addicts as they are, scared as they are, mortal as they are, naive as they are, foreign as they are, weak of mind or body as they are, helpless as they are. If we were suddenly forced to live indefinitely on the streets like our community’s homeless do, how quickly we might realize how similar we are to them in shape and smell. If our drugs of choice were suddenly criminalized (choose one: sugar or alcohol or coffee), how quickly we might realize with a broken heart our unity with those caught in addictions to criminalized substances, and how quickly we might realize the “liars” that we all are.

The emergency medicine clerkship has been nothing but learning. Some of the biggest lessons for me have been in skills such as suturing or interpreting radiographs or crafting a thoughtful differential diagnosis, yet some of the lessons that made the biggest impact were ones regarding the practice of patient education and communication. Working in emergency medicine felt like being at the pulse of healthcare. I saw people receiving life-changing diagnoses or reassurance that there was nothing amiss with them. I saw life-saving interventions and simple interventions. I saw patients who had never in their lives been to a doctor for a check-up and those who maybe didn’t fully understand how the healthcare system in the United States works; some came in for complaints that were probably better suited to a primary care clinic and then other people came in with true medical emergencies. Through each encounter I had with a patient– regardless of their health literacy or level of acuity– was an opportunity to glimpse the privileges and pitfalls of medical practice in the emergency department. Ultimately, I think I’ve grown as a person because of this clerkship. In some way, I feel more aware of my own humanity, including the dark shadowy parts full of cobwebs– the ones that my patients showed me.

the ultimate journey

~ karuna ~ Leave a comment

The following writing is a reflective piece I put together some months ago while rotating through the internal medicine service of the hospital. I wrote it on the day after I found out that one of my patients was certainly going to die because of the cancer that was growing in his bone marrow. The writing contains my reflections on some of the more perplexing realities of working with someone who is dying from a terminal illness. I think it speaks to my growing interest in the field of palliative care and also the work that chaplains do.

Looking back on the writing now, I feel like Mr. C’s case was so touching for me because it pushed me to my limits of being able to “take care” of someone. I feel like I ran up against the boundary of my training and my personal skill as a communicator with him, which was a humbling experience. Working with Mr. C pushed me to be more honest, more patient, more willing to be uncomfortable, more willing to show up even though I knew it would be hard. I had to admit what I didn’t know and be honest about what I did; I had to let him know what I could offer him and what I couldn’t. I should also mention that all my interactions with him were taking place in Spanish, my second language, which added another layer of meaning and challenge. He inspired me to refine my skills with medical Spanish and vocabulary that would be handy in difficult situations that require empathy and validation as well as discussions of existentialism and spirituality. Overall, I think I became a better listener after so many mornings spent sitting at the side of Mr. C’s bed, checking in on his progress or his latest set-back. All I truly could truly offer him was my presence. I hope, in some small way, me being there consistently and trying to be fully present– ready to listen to his experience and ask him questions or bring him water or a straw for his Ensure– was helpful.

In the following writing, I reference Atul Gwande’s book, Being Mortal. PBS just published a short documentary about the big take-aways from the book. I’m looking forward to watching it soon. Check it out here for free: https://www.pbs.org/wgbh/frontline/film/being-mortal/

Mr. C’s battle with leukemia, summer 2019

I’ve accompanied Mr. C as part of his care team since his first day of admission to the hospital. He is a 48 year old man with no significant past medical history who presented to the hospital with weeks of pancytopenia, B symptoms, and a few other cutaneous issues. Suspicious of cancer, we ordered a bone marrow biopsy for him on day 1 of his hospital stay. It’s now day 23.

I’ve seen him almost each day of his induction chemotherapy with cytarabine and daunarubicin. On his last day of his first week of chemo, him and I had developed enough of a relationship that he opened up to me about how difficult his situation is; his journey had started to break him down emotionally. He shared that he wonders if the fight is worth fighting, and he mentioned that he felt like maybe it’d be better if God just took him home. With tears in his eyes, he shifted the conversation to me: “tell me, do you think I will I recover from this?”

I felt deeply uncomfortable with this question because I didn’t know exactly what to say to him. He was in a very fragile emotional state, and his physical condition was pretty abysmal due to the chemotherapy. I knew from my reading and talking with his oncology team that his type of leukemia is unpredictable, and the chemotherapy, which knocks out his entire immune system, is brutal. The anti-fungal, antiviral, antibacterial medications he’s on have multiple side effects. He could succumb to an infection due to profound neutropenia (deficiency of neutrophils, a type of infection-fighting white blood cell) secondary to chemo. The loss of blood cells and platelets could render him at risk for bleeding or decompensation or anaphylaxis (allergic reaction) due to donor blood cells used to supplement his low supply.

Knowing all of that, I told him it’s impossible to know what the future holds for him. Some people respond well to chemo, some don’t. There’s a chance he’ll get better and there’s a chance he won’t. A cancer like his has no clean algorithm, no clear predictive story to offer patients. I believe he could recover, and told him that. But I didn’t tell him that the possibility of him recovering shrinks in my mind as the days go on and he remains profoundly neutropenic. Maybe I was too scared to say something so honest to him, because I didn’t know how to handle the possible emotional fallout. Was it even my role to be that honest with him even if he point-blank asked me whether I thought he’d recover? I also got scared that I might be giving him some kind of false hope or faulty information, so I qualified my words as best I could by telling him that his cancer doctors know more than I do and that hopefully they’d be able to offer him more answers. Whether any of my interaction with him was the “right” thing to do still puzzles me. My only solace was that he had a good palliative care team and oncology team working with him, and that whatever I said would simply be one voice in a sea of voices talking with him about his condition.

Another bone marrow biopsy awaited Mr. C after the end of his first round of cytarabine/daunarubicin therapy. His bone marrow pathology transformed from MDS with 5q deletion to persistent AML; his bone marrow blast count increased to 27.5%. Patients like him need a transplant, but he has no insurance or funding and thus no way to pay for the very expensive procedure and immunosuppressive drugs. All we can offer him right now is more chemotherapy at some point in the hazy future when (if) he stops being neutropenic. His prognosis is quite poor. The prognosis has always been tenuous, even from the first bone marrow biopsy that showed myelodysplastic cells in his bone marrow, but now it’s profoundly troubling. It is highly likely that he will perish because of this cancer.

This morning, I got to the hospital a little early to spend extra time with him, knowing it would likely be a tearful and difficult morning check-up on him. He immediately wanted to talk about the unfortunate news he received yesterday. I told him that I had seen the oncologists’ notes in his file. He asked about chemotherapy– the only and last ditch effort we can offer him to try to stave off his cancer. He will start chemotherapy again when his body is strong enough to do so (we think he might have an infection right now and his neutropenia makes him unstable for chemo right now), but we don’t know when that’ll be. He wanted to know how many more rounds of chemo he will need– another question for which I have no answer. He seemed truly devastated. I told him that the choice to keep fighting and going through rounds of chemo is his choice to make, and his care teams will support him in that. He said that the cancer doctors he spoke to yesterday– the ones who broke the news to him about his bone marrow biopsy results and prognosis — made no mention of this cancer being uncurable; he told me that it’s not that the doctor said the cancer is curable or treatable but rather that he never said that it wasn’t curable. For that reason, he told me he wants to fight the cancer if there’s still any chance of getting better.

This caused tension in me. Mr. C will keep fighting because he believes it’s possible to overcome this cancer or at least go down fighting. I admire his tenacity, but I also can’t deny the conflict I feel inside of myself as he states those words. Is he truly being supported in this fight? He barely has any social support or family; his hospital room is often void of visitors or even the token items of condolence and support sent to patients’ rooms (balloons, cards, flowers, stuffed animals). Is he receiving information about his condition and actually processing it, internalizing it? Or is it somehow not getting through to him because he is in such a fragile state right now? The fear in his eyes and in his voice is haunting, and not a single advocate seems to be present with him to help him make decisions or process the information he receives. I have so many questions about his thought process. Does he understand his quality of life will likely suffer more and more because of continued chemotherapy? But does he even have any quality of life with such a difficult cancer such as AML that goes untreated? What is his level of acceptance of death right now, both in a general sense that one day he (and all of us) will die and in the more acute sense that the odds that his present illness will end his life are very, very high? What areas of his life are left unsettled for him? What can be done in his remaining lifetime? What meaning does he make out of this situation? Does he feel secure in his beliefs regarding what awaits him after his life ends?

On a personal and professional level, I wish I knew how to talk to him about his impending death– a death that will quickly approach maybe in months or weeks, depending on whether or not he can restart chemotherapy. Atul Gwande’s Being Mortal comes to mind. The questions he asks people long before they are devastatingly sick are ones of priorities, life goals, and fears/worries. They include questions like “What matters to you? What outcomes are unacceptable to you? What are you willing to sacrifice and not? And later, what would a good day look like?” Ideally, these questions are asked when people are facing the beginning of terminal illness. Mr. C is already approaching death’s doorstep, and I can’t help but wonder how and when these types of conversations about end-of-life could’ve happened much earlier than now. I would’ve liked to work with Mr. C on answering these questions very early in his disease state rather than during the chemotherapy induced nadir of his disease.

A quote from Siddhartha Mukherjee’s The Emperor of All Maladies: A Biography of Cancer also comes to mind when thinking of Mr. C’s situation.

“In an essay titled ‘A View From the Front Line,’ Jencks described her experience with cancer as like being woken up midflight on a jumbo jet and then thrown out with a parachute into a foreign landscape without a map:

“There you are, the future patient, quietly progressing with other passengers toward a distant destination when, astonishingly (Why me?) a large hole opens in the floor next to you. People in white coats appear, help you into a parachute and — no time to think — out you go.

“You descend. You hit the ground….But where is the enemy? What is the enemy? What is it up to?…No road. No compass. No map. No training. Is there something you should know and don’t?

“The white coats are far, far away, strapping others into their parachutes. Occasionally they wave but, even if you ask them, they don’t know the answers. They are up there in the Jumbo, involved with parachutes, not map-making.”

I feel that Mr. C is deeply alone in his map-making, and I feel like a terribly ineffective companion on his journey. I’m one of the white coats in the jumbo jet; not only do I lack a whole lot of time to spend with Mr. C in his ICU room, but I feel that I literally lack the language and skills needed to support him in his processing of his condition. I want desperately (I feel so profoundly compelled) to help ease his transition toward death, but I have no idea how. I desperately want to work with him to help him find a sense of peace with life as it is: often different from what we expect it to be, often messy and uncomfortable, but also so rich and beautiful in its complexity as a tangled web of inter-related creation.

———————————————————————————————-

Epilogue:

I got a chance to visit Mr. C one last time on my last morning of my internal medicine rotation. I explained that I was moving on to a different rotation and that I wished the best for him. We exchanged words of gratitude and well wishes and goodbyes. Weeks after I left the internal medicine service, I learned that Mr. C ended up receiving one more round of chemotherapy not long after my last conversation with him and then was discharged from the hospital to move to Houston to stay with a family member for the remainder of his life. I don’t think I’ll ever know how his story unfolded or is unfolding, but I do wish him the best.

dislocated joints

~ karuna ~ Leave a comment

It’s difficult for me to judge if my dislike of certain rotations through medical specialties/sub-specialties comes from a genuine dislike of the type of work required for the specialty or if it’s simply a reflection of my dislike for 1) the faculty I work with in the specialty, 2) the specialties’ working conditions, or 3) more broadly the ecology of the healing environment.

faculty as… role models?

The interpersonal dynamic in the emergency department at one particular hospital where I work is an example worth highlighting. Physicians I work with there have been less than welcoming and sometimes even outright condescending toward me. The one that was actually kind to me and helped me try to learn something new during one of my shifts also spent half of the time on shift talking with the other physicians about finances and how big their retirement funds are and/or gossiping about one of their colleagues who I happen to have as a professor (and who I happen to find is a very kind and generous teacher). That dampened my respect for the whole group of them, unfortunately. I enjoy the work of emergency medicine (figuring out what the diagnosis is for any individual who walks into the ED), but the work environment and the personalities it seems to attract are less than appealing.

On a different note, my pediatric outpatient faculty were some of the kindest, most generous, and most flexible physicians I’ve met thus far. They openly valued families (including their own!) as much as they valued their profession, and their priority was always establishing comfort, honesty, and education in their relationship with patients and their patients’ parents/guardians. They were active members of patient advocacy organizations and legal-medical partnerships. They seemed happy in a way that seemed qualitatively different from other physicians I’d met. I admired them.

working conditions

Let’s take part of my pediatrics clerkship as another example. Specifically, let’s examine my week-long rotation in the newborn nursery. I worked in a closet. Literally. When not examining a baby in a patient room or in the incubators of the nursery, I spent hours reading, typing notes, and studying in a closet. The workroom for trainees and students is a 12 ft x 12 ft former equipment storage closet that’s been converted into a workroom. We worked at computers and desks stuffed into a very small windowless space. No better way to go a little crazy when working a 12 hour shift when your home-base is a closet. Unfortunately, the physicians’ workroom is only slightly more pleasant, as it is also an oversized closet with no windows that happens to have soft lamp lighting rather than harsh fluorescent overhead lighting. I think this example is so valuable because it illuminates a small piece of medicine that I find rarely talked about: physicians and trainees as capital. The political economy of medicine is not divorced from capitalism and its exploitative necessities. This is a recurrent theme of my clerkships that likely deserves its own separate post.

ecology of medicine

Ah, and the best example for last: my primary care clerkship site. Now, my primary care preceptor truly deserves a post of his own; I can already see the title of that piece of writing, in fact. It would look something like, “Where the #MeToo Movement Meets Medicine,” and as you can probably guess, it would be an essay about the intersection of mysogyny, toxic masculinity, and the practice of primary care medicine. I won’t launch into a full analysis of my experience right now, but allow me to dive into a few observational sketches regarding my experience. My preceptor is a middle-aged man who operates with many unchallenged assumptions, theories, and “truths” about the world. For example, he believes male ObGyns are better than female ObGyns and will only refer his female patients to male ObGyns. He believes part-time physicians are phonies and care more about going to “yoga class” than “doing something that has merit in the world”; he criticizes people (women) who choose to be part-time physicians in order to also raise a family. He also believes that wearing gloves while examining men’s genitals is a reflection of prejudice on the part of the physician (or in my case, a trainee), yet he purports to always wear gloves when examining women’s genitalia. He also gives unsolicited advice to me about my appearance or about what I should do with my life. And don’t even get me started about me being “pimped” (med training lingo for “quizzed”, “grilled”, “roasted”) in front of patients in their exam rooms that he likes to do…

Beyond these discrete examples of his unchecked beliefs and his own biases, he operates his primary care practice in a cultural milieu that is worth pointing out. His patients are almost exclusively older people aged 40+, and his clinic looks to be straight out of the nineties or the early aughts. I don’t believe this is a coincidence, because he operates under an old-school type of doctor-patient relationship that is ultimately paternalistic and not necessarily keeping pace with interpersonal/political/social advances in medicine. A few examples: He prescribes unsolicited marriage counseling, personal psychological assessments, and life advice to men (and maybe women too, but I’ve never seen that). He tells his patients what to do without establishing the patients’ goals for their health/life, and he operates with full deference and thus without any challenge from his patients. In short, he does not practice shared decision making and he is often not forthcoming with his patients in regard to why he is prescribing certain medications or why he is ordering certain blood tests or radiologic studies. This is a kind of model of “doctoring” that puts physicians in a place of extreme privilege and endows them a font of authoritarian power from which to unceasingly draw. And ultimately it robs patients of their autonomy.
While I have absolute confidence that this particular doctor is operating with his patients’ best interests in mind, I hope to never be like him when I am a licensed physician. I guess that means I’m having a good learning experience at this clerkship site?

Overall, my clerkship experiences thus far have been galvanizing. I don’t particularly like any specialty I’ve seen so far, but not necessarily because I don’t enjoy the work that the specialty entails. I believe it’s due to the toxicity of the environment, culture, and interpersonal dynamics I see in each specialty. I want to desperately do something radically different than all that I’ve seen thus far. Which leads me to a challenge: how will I be such that I will not re-create these problematic patterns in my own practice?