Let pain be your guide
Sunday, November 30, 2008
Anil
As a resident, I am constantly learning. And, I think, so are most of the attendings that help guide me. Every so often there comes a case that is as startling as a splash of cold water. The dangerous disease lurking behind the benign presentation can keep the hairs on the back of your neck erect for months. Something very similar happened just yesterday.
In room 7 waited a 54 yo man with a history of
kidney stones and a complaint of pain in his lower back. I've never had a kidney stone and from what I have seen I am happy not to experience that pain. This man held his lower back with his left hand and grimaced in pain, so I quickly put in orders for medication and told the radiologist to keep him in the cue for a CT scan. We usually do not give
contrast when we look for a kidney stone, which means that there is no dye running through his vessels, and the stone often appears as a
bright rock in the
ureter.
After about an hour, when the scan was completed, that bright rock never appeared in any of the images. And, despite receiving a heafty dose of
Dilaudid, he still complained of a severe pain and clutched his lower back which was very tender to touch. A healthy, middle aged man, with normal lab tests, and a normal non-contrast CT scan is usually pretty safe. Nonetheless, his level of pain seemed to indicate something different.
Though my experience indicated that this patient was probably just fine, my intuition and his pain drove me to keep searching. I checked his abdomen with an ultrasound, looking at his gall bladder which seemed normal, and I moved closer to his left, where his pain was, to look at his aorta which also appeared to be normal. A constrast CT would inject dye thorugh his vessels and allows the scan to show more subtle findings such as a
tear in the aorta. We agreed to do this study and discovered that he did, indeed, have such a tear.
As I reflect on his case, I feel relieved that he is now doing well in the hospital and I am glad that we kept digging. Sometimes pain is hard to control, but it is always our best guide to finding disease in any individual.
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Taming The Jealous Mistress
Sunday, November 16, 2008
Sean Donahue, DO
“Medicine can be like a jealous mistress if you are not careful Sean….” These words were spoken to me 10 years ago by a much older, and at the time, possibly wiser Orthopedic Surgeon. The man was in the waning days of his career, and at 65 years old was currently working on his third marriage and had a 3 year old son. I listened to his words, but I could not fully appreciate the gravity of my chosen career. I remembered thinking, “this guy must be crazy…he is still working 80 hours a week, he failed 2 prior marriages, he is now remarried…and has a small child….and he is telling me about how Medicine is like a jealous mistress…” But as time went on, I realized a specific pattern starting to develop in my associations with other physicians: many of my father’s friends who were physicians were divorced. Many of the physicians I was starting to work with were divorced. Some had remarried; some were working on their 3rd or 4th marriage-starting anew. Many were estranged from their own children. A few even had problems with drugs and alcohol. Maybe there was something to the “jealous mistress” thing. Could the job really be the only blame? Of course not, but my chosen career, like many other jobs which require a high degree of self sacrifice can, if one is not careful, become really like that other person in your life.
I have reflected on my life over the past 10 years since starting my career in Medicine. For the most part I have given up the luxury of weekends off and 9 hour work days. I cannot even count the times I left the house at 600 AM, only to return exhausted at 900 PM, for 6 days straight. I used to think medical school was rough-only to find Residency 30-grit rougher. Not only is Medicine the ultimate time monger, but our work also involves great personal sacrifice…caring for others in need. It is very difficult to place into words how mentally and emotionally draining this care can be…particularly in the Emergency Department. Day in and day out we work in a fast paced pressure cooker. Here, our patients do not care about the type of day we are having; a dying patient need not to know that you are having marital problems, or that your kid is failing school. Many physicians have to completely compartmentalize their life from their work-your normal life gets shoved to the dark recesses of your mind for 12 hours. When leaving work after a draining shift-the reality of medicine, and the stress of your day dissipates, only to be met by your life’s real problems. As many physicians with problems outside of work admit-whether it is marital, drug or alcohol abuse,” they just do not have the energy to deal with their real problems.” They either turn to something else, or dig in deeper to their career. Everything about her is seductive: the time, the pressure, the stress, and the commitment.
I think this is where the notion that Medicine is like a jealous mistress begins…and ends. I have come to realize that I, or any other physician, cannot blame our career on our life’s troubles. Sure the job demands much more than the average, but it is our choices which ultimately determine our happiness. I am reminded of a quote by the late John Candy: “Like your work, Love your wife.” Amen. I recently have had many new aspiring physicians ask me “how do you balance work and home life?” It is not easy. But priorities are paramount. I vowed early on that my wife and children will always be paramount-they are my number one, and my job will never replace them. I tell newer colleagues if they want to be surgeons, if they want to do research, if they want to be leaders of their chosen profession, that is wonderful….but these aspirations will require great sacrifice. Just do not sacrifice what is truly important-the ones who love you. Very few, tread in these waters and maintain the harmony between work and family life they or their families expect.
“Medicine can be like a jealous mistress if you are not careful Sean.” He was right, you do have to be careful, but we are in control of our own destiny. We choose our own priorities, and these dictate the life will lead. After a grueling 12 hour day in the Emergency Room-after the stress, the chaos, the heartache, and triumph-I know at the end of it all, my wife and child are waiting. Everything else melts away. The mistress once again gets the boot.
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Desert Halloween
Saturday, November 01, 2008
Anil
Today is Halloween and I am celebrating it with a costume made of bandages. One roll of elastic tape can make you look like the mummy, a creature from Pans Labyrinth or just Robin. I am also celebrating it with over one hundred competitors from the race. Sometime between yesterday at 10 p.m. and today at 2 p.m., they finished a 54 segment of the race. That makes four marathons and one double-marathon. At the end, most runners successfully completed the race. The things that stopped a few were stress fractures, torn ligaments, and severe dehydration.
A surprising number of runners with IT band injuries pushed on for miles through the pain. The iliotibial band runs from your hip on the lateral side (outside) of your thigh to an insertion point near your knee. With strain and asymmetry, it gets tighter and begins to rub against the bone. This creates a sharp knee pain with running that is only relieved with stretching, rest (sometimes for months), ice anti-inflammatory medication, and massage. Unfortunately, most did not rest or have time to stretch, thus aggravating the problem.
The runners I've treated struggled with IT band pain for months, to even a year, with intense efforts at rehab. After rest cures the pain and running is ceased, the underlying problem requires a more relaxed muscle. That can only be achieved with stretching and rolling. The foam roller is a simple invention that amazes me. A cylindrical piece of foam, in the proper hands, doubles as an expert and powerful masseuse. By placing the roller and body weight on the latter-lying IT band, a back and forth movement can slowly roll out the leg. This is one of the few things I have seen really cure this injury.
I don't expect to see any of the desert. It is over 100 degrees here again, with endless sand dunes and at least a cool breeze. In the end, all these days in the desert are unforgettable. Despite the heat, lack of shower or clean clothes, nights without light pollution, and with stars that beam brighter than any location I have been—all this has burned into my memory. The runners' triumphs have also been inspiring. One Korean runner completed the race without seeing the sights because he was blind. He had someone lead him through the course by rope, and finished with great speed.
I am ready to head to the trail myself now when I get back.
Anil
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