A doctor's tools

I like to think of myself as a minimalist when it comes to running tests and ordering medications in the urgent care. The nurses love it. My mother hates it. “You mean all you do is give them Motrin and a popsicle? That’s it?????” Yes, mom, that’s it. That’s all they need. Most pediatric disease is self-limited, either caused by a virus, or idiopathic (that wonderful term for “we don’t know what causes it”). Most pediatric injuries heal without major intervention. And so running a bunch of expensive, sometimes invasive tests that will most likely be normal seems like a waste in every sense of the word.

Plus, there’s a reason I went to 4 years of extra school and 3 years of indentured servitude residency. It’s called making a clinical diagnosis. You know, what doctors used to have to do for every patient, based on a good history and a thorough exam. They had to know how different heart murmurs sounded, because there was no same-day echocardiogram. They had to learn the signs of heart failure, because measuring brain natriuretic peptide hadn’t been discovered yet. And yes, they had to do a rectal exam on patients instead of getting xrays to diagnose constipation (which is still a more effective diagnostic tool, by the way). Call me crazy, but I like being a clinician instead of merely an interpreter of lab results and imaging. I pride myself on it most of the time. I spend a lot of time convincing parents that it’s a better way to go.

But if you want to make me doubt my clinical skills, if you want me to long for the ability to check a quick BMP or grab a chest x-ray, frankly, if you want to make me feel helpless, then take it all away. Put me in a teepee on the side of a mountain trying to tease out post-surgical abdominal pain in a teenage girl. Or on the phone with a worried friend who doesn’t want to make an unnecessary ER visit for her child. Or on the flag football field when someone goes down with a “pop” in one of his joints. My calm reassuring voice becomes laden with doubt, and I forget all of my training. Or at least that’s how it feels. At least for a moment. Then reason kicks in and I start to work through the problem, ruling badness in or out, looking for red flags, gathering as much information as I can.

The few physicians in my Wilderness First Responder course were sick of being outside the hospital, without any of our normal comforting resources (labs, radiology, even monitors) and not knowing what to do. We all needed a reminder that we are, in fact, clinicians first. We can use our eyes, our hands, and our brains instead of machines. I try to remind students of this when they rotate through the urgent care. It’s what I try to practice on a daily basis, even when I don’t have to, because it makes me a better doctor when I do have to.

And in reality, a popsicle is sometimes all the tool we need.

I hate fasting (I'm just gonna say it)

For someone who thinks about food as much as I do, fasting for Ash Wednesday and Good Friday are pretty much the highest form of emotional, mental, and physical torture that anyone could inflict. Which I think reiterates why I need it so much. Hear me out.

On a typical day, I wake up after having gone to bed the night before planning my breakfast. The important thing is a balance of sweet and savory, not too heavy on the dairy, and easy to make. I also need an adequate (but not too large) "second breakfast" if I'm working (needs to be portable and preferably quick to heat/eat because I can't use my "lunch break" on second breakfast). Don't forget the coffee, and if I went too light on the sweet side of things, breakfast dessert. As soon as I'm done with second breakfast, I'm thinking about lunch. Whether I'm in the mood for it, whether I can wait long enough, whether I'm going to have enough time to eat it, whether I remembered dessert. I try to have all the food groups (meat/protein, chocolate, fruit/vegetables, simple carbs with extra sugar, grains, dairy) and adequate portions. I usually roughly count the calories when I'm packing my lunch the night before. Then the question is whether I indulge in an afternoon beverage. If I'm at work, maybe a diet soda, green tea, or Crystal Light. If I'm off, something more in the alcoholic category. Dinner is mostly making sure I have enough protein to silence the tummy rumbles and an adequate dessert. And then I'm thinking about tomorrow's food.

Whew! I'm exhausted just writing about it. Imagine being in my head all day. There's no time to think about anything else. So when Ash Wednesday rolls around, I usually start the panic thoughts a few days in advance. What can I eat for my third meal that's bigger than the two small meals but not gluttonous? Do I have enough tuna packets for Ash Wednesday and that Friday? What's the best timing of the meals? Do I give up coffee and risk the caffeine headache or just drink it black as mild penance? How can I make sure I still have enough protein/fat so my blood sugar doesn't drop (this last one is a very real concern; remember, I'm a fainter)?

Add to that the complicating factor of working a 13-hour shift on Ash Wednesday. What if my blood sugar drops while I'm in a patient's room? What if I need to eat but can only get in half my meal before a sick patient comes in, then can I finish it later or does that count as an extra meal? Can I even stay up that many hours while fasting? (I usually try to sleep for most of these days if I can. Less awake time=less cranky time.)

And then there's the actual fasting. My tummy grumbles...everything makes me think of food...someone ordered pizza...I deserve a donut...wonder what my blood sugar is now...how many hours until lunch...does a graham cracker count as dessert...I'm weak and cold and have no energy. By the end of the day, I am not a happy person.

And all the while, my strangled soul is screaming GET A GRIP!!! I STILL got three meals. I STILL had access to clean water. I STILL had a warm bed to crawl into. I STILL get to wake up the next day and gorge on donuts. God will provide. Again and again and again. I do not need to be thinking this much about food. I need to be thinking this much about God, and what He wants me to do with all the gifts I've been given. I need to be made a little uncomfortable, because clearly my body is used to getting its own way. So, as much as I loathe fasting, this is perhaps a good reminder to me to do it more often, so that it becomes easier. Because I can't get much worse at it.

The end of suffering?

Last night I attended the 8^th Annual Great Debate in Boulder—sponsored by the Aquinas Institute for Catholic Thought—discussing physician-assisted suicide and whether it should be legalized in the United States. It proved an incredibly relevant topic given House Bill 1135 which will be brought before the Colorado legislature tomorrow. It’s also fresh in everyone’s minds given the recent celebrity of Brittany Maynard.

One thing that stood out from the debate last night was that in order to truly debate this topic, we must share a frame of reference, a vocabulary of morality and ethics, and in a sense, we have to agree on a certain worldview. For example, if you think that a person should be able to do whatever they want with their body regardless of the consequences, and that the law exists to protect that premise, then we have nothing to debate. For the rest of you, I offer the following considerations. (Sorry, they are not brief).

The basic premise of those in favor of physician-assisted suicide (PAS), reinforced by Dr. Michael Tooley’s arguments last night, seems to be that there are certain cases in which death is preferable to life, in which someone is “better off dead” (Dr. Tooley’s words), in which bringing about one’s death is a “benefit rather than a harm” (again, his words). Dr. Tooley asserted that it is up to the dying person to decide what that cutoff is. He specifically supported PAS in cases of extreme physical pain and suffering (and notably rejected it in cases of depression, temporary or sudden disability, or emotional suffering…hmmm).

This viewpoint has arisen, argued Wesley Smith (the other participant), from a shift in philosophy. Historically, from Plato to Descartes, virtue was regarded as the primary human good, primarily the virtues of knowledge and wisdom. But as advances in science gave humanity control over the natural world, Descartes directed his efforts towards “the conservation of health, which is without doubt the primary good and the foundation of all other goods of this life.” That’s a huge paradigm shift, and if you take it to its logical conclusion, humanity has a right, even an obligation to advance science in order to conserve “health”, at the expense of virtue or any other good.

Given today’s aversion to physical and emotional suffering, and our narrowed definition of health as “the absence of disease” rather than “complete physical, mental and social well-being”, it might make sense that we can and should use science to help us avoid suffering at all costs. To the extreme conclusion, as Smith put it last night, that “killing is an acceptable response to human suffering.”

I would argue that Descartes was wrong, or at least that we have warped his philosophy to an unsatisfactory conclusion. If health is the be-all-end-all, then is life really worth living? Are healthy people really the happiest, the most successful, the most virtuous? Have they truly achieved the greatest good? And if so, then what worth do unhealthy people have? It’s not a far leap to discount the disabled, the sick, the suffering as worthless. And yet, we know that’s not true. Consider Stephen Hawking, Helen Keller, FDR, who knew that they were more than their health, or lack thereof.

Yes, an appropriate response to suffering is to try to alleviate the suffering, but I think we have to realize that the absence of (especially physical) suffering is not the greatest good, to be achieved at all costs. Human life has dignity and purpose in the midst of suffering, and to let someone believe that a certain amount of suffering makes them “better off dead” is, as Smith said, abandonment.

Studies have shown that people requesting PAS primarily are afraid. Afraid of becoming a burden, afraid of losing control, of losing their dignity, afraid of not being able to do things for themselves. I think ultimately, they are afraid of losing their identity, their voice. By telling them they are better off gone, aren’t we agreeing with them? Shouldn’t we be reinforcing their worth, helping them achieve a measure of autonomy, allowing them to have a purpose, a place in a community?

This doesn’t even get into the slippery slope of deciding that there are certain populations who are “killable”, or the dangers of not treating mental illness appropriately, or the financial pressures of euthanizing over continuing medical treatment. It doesn’t get in to the dilemma of a physician who has taken an oath to “do no harm” being asked to kill. And it certainly doesn’t broach the argument that life is a gift from God and isn’t ours to take. I hope instead that by questioning the very foundation that suffering is an evil to be avoided and that killing is an acceptable answer to that suffering, that I can reach a broader audience, and help people think a little more critically about where our society is headed.

Also, please visit http://www.cocatholicconference.org/voter-voice/?vvsrc=%2fAddress to find your state representative and tell them we should not legalize physician-assisted suicide.

Tony, Tony, come around

This week I found two things I had been missing for quite a while. The first was a down glove, worn nearly all the time in the winter, a favorite--probably fallen out of my jacket pocket at some unknown location, and I never expected to see it again. I was at work on Wednesday and lo and behold, there it was, perched on the coat rack in the locker room, lonely and waiting for its owner. The second was my consecration bracelet, of which I have lost more than any one person should in a lifetime. I assumed I lost this one while shoveling one day and so was waiting for the snow to melt, confident that I would find it eventually, but impatient for that day to come. And so for this I implored St. Anthony, patron of lost items, with a confidence that I couldn't explain. I found the bracelet two days ago, while loading a piece of furniture into Michelle's trunk (long story) and there is was next to the ice scraper and the washer fluid. Tony comes through again!

Devotion to St. Anthony, especially in relation to lost items, has been a Catholic practice for many years. It is believed to have arisen from an incident in the saint's life, where he prayed for the return of a psalter (book of Psalms) that had been stolen, and the thief was moved to bring it back. Since learning about this devotion as a teenage, the words "Tony, Tony, come around, something's lost and can't be found" have crossed my despairing lips many times. In some ways, I hesitate to put faith in his intercession, because is it really any different than the superstitions we are to avoid? And yet, he has never, never failed to lead me to the lost item (except for the previous 4 or so consecration bracelets), so I also hesitate to abandon the practice.

This most recent time, when my consecration bracelet once again went missing, I immediately called up St. Anthony, and felt a peace in my heart that he would answer. I sensed that God wanted me to trust Him, wanted me to find it, and wanted me to delight in His help. And that I think is the distinction. Between superstition and intercession. God delights in us, and wants to show us His delight. I feel this every time I see a beautiful sunset, whenever a white butterfly joins me on a hike (it means Grandma is with me), and every time one of my obscure prayers is answered in an unexpected way. And I think He delights in showing me that He can surprise me in the little things.

Several weeks ago, Michelle had lost a favorite ring and had invoked St. Anthony's help. A few days later, I found the ring in a bowl of grapes in the fridge; it had come off while she was washing them. She was ecstatic. Delighted. Just as I was when I found my glove. And my ring. I smiled at God: "You've done it again," I thought. Just as someone leaves a love note, God wants to show us that we are always on His mind. And that the saints are a powerful aid for all things, great and small.

So I will continue to trust in St. Anthony's intercession. Not because I am superstitious, but because I believe in God. He can choose to answer either way, and it doesn't change His power or His love for me. An item that stays lost doesn't mean I didn't pray hard enough or the right way; just that it stays lost. God still is. And He still delights in me.

I kind of want to post this everywhere

I know that Urgent Care is easy. And the hours are better. And you’re busy. But there are just some things that shouldn’t be seen at Urgent Care. To avoid the frustration of multiple trips, waiting too long, leaving with no answers, or being judged based on your chief complaint (it happens; I’m not proud of it, but at least I’m honest), try to follow these rules.

1)      We do not have unlimited access to specialists, nor will the specialists see you sooner if you are in the Urgent Care. We get countless walk-ins and even referrals from doctors wanting their patients to have an echocardiogram or EEG, see the pediatric dentist, or get in sooner with their rheumatologist. It’s not going to happen. If it’s truly emergent, you may be admitted at our main campus and see those specialists within 24 hours, who will then decide on any workup/treatment. Otherwise, we have to go through the same channels your pediatrician does to get to the specialists, and the vast majority of the time, we are only consulting by phone, often with a resident, fellow, or mid-level provider. The end result is usually adding you to their growing appointment list, often months out. If you want a specialist, have your doctor call them instead.

2)      Please don’t come in with 6 months of chronic symptoms without seeing your regular doctor first. If you’ve had something going on for more than a few weeks and haven’t been able to solve the problem with Dr. Google or with multiple trips to other ERs, chances are it won’t be a quick fix for us either. Our job is to rule out bad things and get you the right follow up, often with your regular doctor. Plus, if we start a lab workup or want to order tests, your doctor won’t always be able to follow up on the results (and chances are we won’t either, since many of the labs and imaging studies come back once our shift is over). Additionally, if you don’t get better in two days and decide to come back, you will be seen by someone different, who will have no idea how you looked the first time, may have a totally different approach, or may disagree with what has already been done. It’s a lot easier to solve long-term issues with a long-term plan—namely, your own doctor who can see you through the illness and follow up on what they recommend.

3)      We are an URGENT care. We are not an “I just had a quick question” or “I didn’t want to make an appointment with his doctor” care. The following are all real complaints that have come in to our Urgent Care or ERs—ear pain for 20 minutes (no meds given at home), band-aid stuck to leg, need a refill on Prevacid (which is now over the counter, by the way), the child felt warm, grandma said he needed to be seen, was exposed to someone with a sore throat but doesn’t have any symptoms. There are nurse lines for these sorts of things. We are always happy to offer reassurance, but please don’t expect me to rush in when I have other rooms filled with asthmatics, broken bones, migraines, seizures, pneumonia, partially amputated fingers, or other things more…urgent. It’s always the people who don’t really need to be there that balk at the wait times. Imagine waiting until your pediatrician’s office opened. In two whole hours.

A perfect day

Halfway through January and yet to post...strong start, Dr. Z. Ah well, I have mostly good excuses.

Today I will tell you about why I love days off. In residency, a day off was a true rarity: about 1 in 6. That's a bad average even for the Rockies. Ouch. And so, those days, while also much looked-forward-to, were more of a survival mechanism than anything. Laundry, grocery, get some Vitamin D, sleep, work out, and probably happy hour, and then it's back to bed in preparation for another call.

Now with more than a day a week to work with, I can relax a little bit more. Not only that, but I live in Colorado, so even in January, my days off can be outside. Case in point: yesterday. My plans were a little thrown when my ski buddy caught the plague (maybe a slight exaggeration), but no matter. After finishing my coffee, I swapped the poles and goggles for gaiters and hiking boots and headed to the foothills.

A not-so-small amount of panic set in when I set off from the car--the only one in the lot at the trailhead--and saw a large sign warning of mountain lions. #shouldhavebroughtthetaser Instead, I gripped my camp knife knife-fight-style and sang loudly and poorly whatever songs popped into my head to warn those lions I was a-comin'. Thankfully, I saw no mountain lions, only three brother deer who did not stop to pose for my camera phone.

I managed to round trip 7.6 miles in a little under three hours, including a lunch break at the "scenic overlook". Not sure how scenic you get at 6,000 feet (it was a little ponderosa valley with a winding road through it), but at least the sun was out and I remember to pack Candy Cane Joe-Joe's for dessert. Plus keeping a decent pace meant I was plenty warm in a t-shirt and pullover, no hat or gloves needed. Did I mention how it's January?

Day not done, because what day off would be complete without margaritas on the front porch (again, January!!), homemade meatballs and almond butter cookies, and playing ninja with a four year old. Yeah, you can be jealous. Shoot, I was a little jealous and I was there! Stayed late enough to miss rush hour but still home in time to watch last week's Blue Bloods and lights out by 10. A great day.

All of this because I was just reading an interesting article about how to fall in love with someone (a different topic for a different day) and one of the questions to ask your partner is "What would constitute a 'perfect' day for you?" Well, I was going to use several of the questions as writing prompts for myself, but when I got to thinking about this, I was a little bit annoyed at spending a bunch of time planning a perfect day, because a) I knew it would never happen, and b) why shouldn't today be the perfect day? I can choose to make whatever I want out of my day. I mean, some days I have to work, some days have other things in store, but all in all, I enjoy my job, I enjoy my life, I have good friends. The perfect day is one where you get to the end of the day feeling loved, feeling accomplished, and say to yourself, "Man, that was a good day". Shouldn't every day be the perfect day? And if not, what excuse do we have besides ourselves?

Thus my day off yesterday shone, and today too, for that matter. Not that you need a play-by-play of all of my days. Cause what a waste of time that would be. For both of us. Now go enjoy your day!

Another year in books

Yes, some people still read. As in books. I do not understand people that say "I don't read books." And I am extremely heartened by the studies that have come out this year saying that reading paper books is better and by the fact that the AAP finally verbalized what all of us have known for some time: that kids should be read to every day. Reading is just good for you. Not magazines. Not Huff Post articles. Books.

However, I do realize that my volume is a little atypical: this year I read 45 books, including 11 non-fiction titles and 8 books-on-tape (which I'm not claiming have the same benefits, but it sure beats falling asleep during my 45 minute commute home from work). And I have decided to share the best with you. Lucky you.

My Top 3 Books of 2014 (in alphabetical order)
The Giver (Lois Lowry, 1993)--okay, this one was a re-read, in honor of the upcoming movie, since I didn't remember much from 6th grade except the sled and the color red. If you haven't read this, please do. It's the original dystopian novel, so much simpler and more moving than "Divergent" or "The Hunger Games". There are echoes of today's society, like "releasing" the deformed, troublesome, and elderly; trying to remove childbearing from marriage; and government regulation of everything. There are people today who agree that all of our freedoms and emotions aren't worth the heartache they cause--but it's a perfect example that life to the full doesn't mean life without suffering, and even if you take all suffering away, it won't bring happiness.

The Invention of Wings (Sue Monk Kidd, 2014)--This book was an incredibly engaging look at slavery in the South shortly before the Civil War. It details the relationship between an idealistic young Charleston woman and her brash waiting maid, as well as the cultural barriers they both face growing up. It's stark, often very hard to read, but hopeful and thought-provoking as well. Any fans of historical fiction, strong characters, or just a good story should add this to their list.

The Spirit Catches You and You Fall Down (Anne Fadiman, 1997)--as I've already mentioned, this book is a must read for anyone in healthcare or that deals with other cultures, but really, for everybody. This book riled me up more than any other book I read this year, and has changed the way I approach medicine (at least a little bit, at least I hope).

5 Other Great Reads
Clear and Present Danger (Tom Clancy)--an intricate spy novel, detailed but engaging
Leaving Van Gogh (Carol Wallace)--a beautiful look at art, mental illness, friendship, and family
Saint John Paul the Great: His Five Loves (Jason Evert)--the latest on JPII, a wonderfully personable portrayal
Station Eleven (Emily St John Mandel)--a science fiction novel of sorts, wonderful characters and a moving story
The Tiger's Wife (Tea Obreht)--lots to think about in this fantastical tale of a young doctor dealing with the death of her grandfather

As always, I'm up for discussions and book recommendations. Here's hoping for more library card use from all of us in the new year.