Rural Doctoring

The Year in Review

I'm not a "holiday person." I don't observe most of the traditions Americans follow for Thanksgiving, Christmas or New Years Day. I have, in the past, made lists of New Year resolutions but I have stopped doing so because the result inevitably causes more anxiety than personal growth. Yet sometimes I find it interesting to take an inventory of the Old Year, not to form new resolutions but to ask myself what I can learn from experience. 

I have to say, 2008 is not going to go down in history as my best year, but there have been some high points:

"Did You Have a Nice Holiday?"

People keep asking me this question, and it makes me want to laugh because I was working over the entire holiday weekend and now I'm feeling a bit like I stepped off the last plane out of Saigon. Recap:

• Christmas Day:  24-hour shift, rounded on sixteen patients and admitted two more. In the hospital for sixteen hours but at least got to sleep in my own bed. Partly cloudy skies, followed by hail and steady rain.
• Day After Christmas:  24-hour shift, rounded on twenty patients (includes four admissions and four discharges), had a very depressing family meeting about an ICU patient. Pouring rain all day, general sense of gloom. In the hospital for fourteen hours, slept at home.
• Saturday:  12-hour shift (hooray!), rounded on twenty patients (includes another 4 admissions and 4 discharges). Had an extremely frustrating meeting with family of ICU patient and a community colleague. General sense of despair and hysteria among the patients who have been cooped up in the hospital over the holiday. Raining all day. In the hospital for thirteen hours. Slept like a log.
• Sunday: 12-hour shift, rounded on twenty patients (incluedes 3 admissions and 3 discharges, I can't seem to tip the balance in my favor), had one more challenging meeting with ICU patient's family and community colleague, had to be firm and advocate for the patient's best interests, and finally we withdrew care. He died peacefully three hours later. Feeling physically numb but emotionally pissed-off. General mood in the hospital is more subdued than yesterday, perhaps because it has been raining continuously for what seems like forever. In the hospital fourteen hours. Return home in a state of collapse.

At first, when people asked me if I had a nice holiday, I said "I was here at the hospital."  For some reason this elicited so many expressions of sympathy and general "awwwww, poor you" attitude that I was in danger of succumbing to despair. So I changed my response to "Good. And yours?" The results have been much more satisfactory. I get to hear about everyone else's celebrations and don't have to relive my own horrors. Management of small-talk is the most overlooked professional skill in medicine.

The Holiday Hospitalist

In what has become the ticker-tape of recent posts, I'll start with updates:

• My partner had her graft examined today and it looks AMAZING! We kissed the home vacuum dressing goodbye, and now she has a plain Adaptic on it and gets to move her arm a tiny bit more.
• The Mac ICU diagnosed a dead hard drive, which has now been replaced so I am glad to say I am reporting live from my own beloved G5 once again. 
• Public service announcement: Back up your hard drive regularly. Don't ask, just do.

Impostor Alert!

OK, in addition to the kerpuffle of getting my partner home from the hospital today, my laptop decided to give me the Grey Screen of Death, so I am reporting to you from her G4 iBook while the G5 is at the local Mac ICU. We are all doing okay although my last nerve is certainly getting frayed with all this activity and the prospect of keeping the two of us--actually, the SEVEN of us if you count dog and cats--afloat with my partner's right arm in an immobilizer, which eliminates her from the dishwashing, pet feeding and laundry responsibilities she usually fills so admirably. 

I've given the situation serious thought and come to the conclusion that this is not our life we're leading, but some other couple's annoying and probably richly deserved existence. Obviously aliens switched our lives with those of the impostor couple, so I want you all to be on the lookout for people answering the following description:

The Myth of Pink Carnations

So it turns out the plastic surgeon wants to keep my partner in the hospital until the vacuum dressing on top of the graft site is removed on Monday or Tuesday. The skin graft is in an extremely awkward position on the right side of her back, with the tail of the graft in the axillary crease itself. This means she's not allowed to move her right arm at all; it is strapped down with a shoulder immobilizer. 

We weren't prepared for her to stay in the hospital so long, but I can sympathize with the surgeon's desire to keep her in a controlled environment where she can't slip up and compromise the graft. However, I'm not the one stuck in the hospital. My partner is. And she's going crazy.

Here's why:

• Her right arm is completely immobilized to protect the graft site.
• Her left arm has a heplocked IV in it.
• Half her head is shaved because the surgeon took the donor skin from the scalp.
• She's vegetarian and the cafeteria sent her chicken for lunch.
• Dinner was vegetarian but she can't really cut up a baked potato with only one hand.
• The hospital has double rooms and is running at capacity, so the staff is harried.
• Her roommate is an elderly, demented woman who keeps trying to get out of bed by herself and objects to the TV being on. So far, all she's said to us is "Mind your own business!"

Hospitalists, take note: this is an example of why people go ape-shit crazy in the hospital. What's the remedy? Maybe a whiff of Risperdal? A stat order to Round Table Pizza? Earplugs? A nice bouquet of pink carnations from the volunteer's gift shop?

We made do with some intensive color swatch discussion (newsbreak: we're going with English manor-house library green walls in the master bedroom) and an emergency run to Blockbuster for movies to watch on a portable DVD player. Her choices:

• Day of the Dead
• Hellboy II
• Hancock
• Batman: The Dark Knight
• Wanted

Obviously she's in a dark mood. I'm not buying green paint yet; maybe after she gets home, she'll change her mind and want the room to be yellow. Or carnation pink.

Skin Graft Today!

What a headline, no? My partner gets her excision site grafted today. With all the decorating we've been doing around here lately--a great anxiety-buster, by the way--we've taken to calling the skin graft process as "reupholstering." 

Yeah, we're crazy.

We Interrupt Our Regular Programming For An Expression of Gratitude

Updates:

• My partner's excision wound is granulating like a champ!
• We are both sick to death of the vacuum dressing, which burps and farts like I imagine Shakespeare's Falstaff did behind the scenes.
• Our plastic surgeon was hoping to do a skin graft this week, but there is no available OR time, thanks to the usual end-of-the-year crush of elective surgeries. People want to get as much medical stuff done before the end of the year because deductibles reset at the beginning of the following year.
• Redecorating and renovating continues apace. We have chosen eco-friendly flooring for the new bathroom/pantry design, and standard countertops for the new sink counter.
• I have painted the dining room a beautiful clear, primary red, and we are going to move the dining table out of there (we eat around the coffee table most of the time) and turn it into a quirky TV-free reading room.
• I still haven't blown up at anyone. Of course, I've been avoiding conversations of any kind so this has not been difficult.

Oh-Oh, Compassion Bypass Ahead

Throughout the recent chaos resulting from my partner's melanoma diagnosis and my own redecorating efforts, I have continued working, although not at a very busy pace--just enough work to be disruptive to what feels like the real business of sorting our belongings into trash/donate/storage piles, and taping the edges of doorways in preparation for painting the dining room red. This is one of the reasons I have always worked continuously, because I find it so much easier to motivate myself when I'm in the middle of a run of ten shifts or six nights on call. Conversely, when I work for a day, have two days off, then work another half day, then the smallest responsibility feels like a major imposition.

Just a Feeling

Last week, I was talking to a 70-ish man with COPD and a variety of cardiac disease (ischemic, valvular). The subject was advance directives and code preferences. 

Things Are Good, Even if I Am Nuts

OK, a couple of updates:

• My partner had a wide excision of her original melanoma site and a sentinel node mapping on 12/2/08.
• The excision margins were negative for satellite lesions. Profound relief and rejoicing.
• A sentinel node and a portion of the wide excision have been sent to Stanford's pathology lab for immunohistochemical testing, which is going to take another week or so to be completed. This is high-tech stuff.
• Her 10x5cm wound now has a vacuum dressing in place. This is taking some adjustment, because the device has to be carried around in a fanny pack all the time. We call it Cousin Albert. The machine emits intermittent bubbly sounds, which we refer to as Albert's flatulence.
• In the middle of all of this, I did three night hospitalist shifts and one prenatal clinic.

Lend a Helping Claw

By the time you read this, I'll be sitting in a hospital waiting room, accompanying my partner first to a lymphoscintigraphy--a nuclear uptake study of the lymph nodes to the armpit near the location of the melanoma--and then a surgical excision and lymph node biopsy. This is not the first time I have sat in a waiting room as a family member, twiddling my thumbs and feeling the self-consciousness those of us in health care invariably experience when in this situation. Because none of us wants to be one of those people, the ones who think their role as a doctor or nurse entitles them to tell the doctor or nurse taking care of their family member how the job should be done.

My Inner Diva

While I was taking my recent mini-retirement, I discovered the reality design competition TV shows on Bravo: Project Runway, Top Chef, Top Design. I've been aware of these shows for a long time--my partner has been a big fan of Project Runway for a long time--and I've always thought they were overwrought, histrionic portraits of total self-absorption. I've never been a supporter of the idea of difficult creative genius. My chosen profession requires diplomacy, collaboration and etiquette, and I didn't understand why anyone should be allowed to bypass those standards just because they create fashion or cuisine rather than the more mundane type of services a doctor provides.