mahiwaga

The Dragonfly Initiative suddenly took me back to those halcyon days of yore, when I could just sit for hours studying things that I find are of little-to-no clinical relevance. Chronic renal failure? Obsolete. It’s Chronic Kidney Disease. Congestive Heart Failure? Obsolete. It’s just Heart Failure, or Decompensated Heart Failure, now. There is no such thing as Non-Insulin-Dependent Diabetes Mellitus, either. It’s either DM type I or type II. Beta-blockers are standard of care in Decompensated Heart Failure. Digoxin is almost useless, except as a way to achieve rate-control in atrial fibrillation. The difference between Q-wave Myocardial Infarctions and non-Q-wave Myocardial Infarctions are academic and don’t make a difference in terms of treatment. What we care about are ST-elevations: STEMIs vs NSTEMIs/unstable angina. And it’s all called Acute Coronary Syndrome now.

Hell, I’ve had to unlearn things I’ve learned during residency already! Erythropoietin can cause serious problems. COX-2 inhibitors are a marketing ploy more likely to cause Acute Coronary Syndrome. LDL is not the end-all, be-all of risk stratification for Coronary Artery Disease. No one I know has actually ever seen warfarin cause a thromboembolism, and it’s standard-of-care to just start it without bridging as long as you know they don’t have a hypercoagulable condition and aren’t a super-high stroke risk.

I’m trying to think of a situation where medical student syndrome became an issue.

All I recall a couple of cases that my friends and family tried to get me to diagnose over the phone, knowing full well that I was just a mere medical student, and that diagnosis without actually seeing the patient is fraught with massive amounts of danger.

1:

My sister develops severe right lower quadrant pain randomly in the middle of the night. She’s puking her guts out, and one of her roommates tries to describe everything to me over the phone. She also has a fever. I’m thinking that it’s probably appendicitis. She ends up in the emergency room, and the urinalysis is consistent with kidney stones.

2:

My friend A calls me up and reports that she gets right upper quadrant pain about 30 minutes after eating meals, and that she ends up feeling bloated and nauseated. A diagnosis of gallstones flits through my mind, but it doesn’t make any sense. The mnemonic for gallstones is 40 years old, female, fat. A is (or was at the time) in her mid 20s and barely weighs 100 lbs. Gastroesophageal reflux disease (GERD) also floats through my brain. But why now?

Then I remember the old dictum: every female of child-bearing age is pregnant until proven otherwise.

I ask her when her last period was, and it’s like three months ago, and I’m like, “What?”

A laughs and tells me she and E are expecting. Now that was a forehead slapping moment that I won’t ever forget.

3:

My dad starts having bright, red blood in his stool and my mom is a little agitated by this. My dad, who is excessively fatalistic, doesn’t seem to care. He says it’s his hemorrhoids. My mom retorts: Didn’t you have surgery done on them? My dad laughs mirthlessly. We both know that surgery for hemorrhoids is no magic bullet. He eventually gets a colonoscopy, and, what do you know? It’s his hemorrhoids. At least he won’t have to have that done for another 10 years.

I’m glad I wasn’t in medicine yet when I had my chronic cough. I mean, this was really a chronic cough. It lasted from September to March. Non-productive. Non-bloody. No shortness of breath. Just this irritating cough that wouldn’t go away. I don’t really think anything of it at the time, but my mom freaks out and demands that I get a chest x-ray, which, predictably, comes back negative. And yet, for some reason, I didn’t get a TB skin test done.

In retrospect, it turns out that it was probably a combination of a post-viral cough and my latent asthma. This is when I realized that there is no such thing as outgrowing asthma, and I’m going to have bronchospastic airways until the day I die.

Oh, now I remember. I got my testicles checked because I have this lump that turns out to be probably a spermatocele. At least, the urologist didn’t seem concerned.

I got my salivary glands checked out by two ENTs because I kept having (and keep having) face pain. One of the ENTs diagnosed me with sialolithiasis and extracted two stones from my Wharton’s duct. That’s probably what it is, and I’m not sure if I should get anything else done about it. The idea of injecting iodinated dye into the ducts to do a sialogram sounds unpleasant, and knowing my atopic history, I may even run the risk of having a contrast reaction, but I should probably get this taken care of while I have insurance.

Lastly, I remember getting motion sickness and feeling nauseated for days and days, to the point where I was basically just going to sleep after coming home from my rotation. I even saw a neurologist, and they found my exam completely normal, and chalked it up to some form of viral labyrinthitis that should wear off in another week or so. In retrospect, I realize that this was probably venlafaxine withdrawal. Damn that drug.

It’s funny how I feel reassured when the so-called experts can’t figure out what’s going on. Unfortunately, this also means that they can’t figure out how to make me feel better. I’m wondering if I should just get empiric treatment with parenteral penicillin, in case this really is an smoldering case of actinomycosis that’s causing sialolithiasis, although this seems pretty damn unlikely. Although it could explain some of the night sweats. (And, no, my last PPD was still negative, and while I may have converted sometime this year, the night sweats would pre-date the point of conversion. And my last CBC was perfectly normal, so I seriously doubt this is leukemia or lymphoma. But, you know what? You never know. How reassuring is that?)

Bayes Theorem is a powerful, yet oft-misunderstood, tool in medicine. Physicians are probably slightly better than average people at estimating probability, but we’re terrible at adjusting these probabilities in light of data accumulated from clinical diagnostic testing. So, despite the fact that very few people, even when considering people with hypercoagulable states, even when considering people with cancer, develop pulmonary embolisms, anyone with chest pain and shortness of breath that can’t be ascribed to Acute Coronary Syndrome, has a pulmonary embolism, no matter what the tests say. D-dimer negative? I don’t care. Get a CT angiogram of the lungs. CT negative? I think it’s wrong. Get a ventilation/perfusion scan with xenon and technetium-tagged macroalbumin. V/Q scan negative? Who cares. Let’s just anticoagulate the guy. This kind of flawed thinking goes on everyday, at the tune of hundreds of thousands of dollars. I think if they just taught Bayes Theorem for an entire year, we might get better at this prognosticating racket. But maybe not.

It’s terrible, really. Times like these, when it’s sunny and calm and blissful and quiet, is when I worry the most.

I think about all those times that I’ve felt the cold presence of Death draw near. It’s never my death that I’ve feared, although I’m scared of that the way anyone is scared of jumping out of a plane at 30,000 feet, or jumping off of an 500 foot cliff. But that’s just visceral fear—the autonomous nervous system taking control, cutting off your cortex so that you don’t die from thinking too much.

No, what my encounters and near-encounters with death have taught me is the meaning of the word dread. Brooding dread. The kind of thing that keeps you up in the middle of the night, gnawing on the ends of supposition and running through worst-case scenarios, and having to wonder if, when you got up the next morning, you’d be able to bear it.

I’ve talked about the time my dad had his big MI, coming upon three years ago, now. If I didn’t know it before, I understood it then what it means to be outside of the loop. No one ever talked to me, showed me any test results. No one tried to reassure me or lay it all out on the table. It was just silence filled with my fretful worries, some legitimate, some completely out of my ass. I didn’t help that I lived 150 miles away, and that I was still trying to work and commute back-and-forth. I remember trying to take Step 3 of the USMLE during this time period, and I’m surprised I passed.

While the hours fled, measured by the inhuman beeping of the cardiorespiratory monitor and of the pulse ox, me and my mom were working on pure speculation, trying to piece together the fractured fragments of the so-called practice of medicine while my dad suffered in his bed in the ICU, barely awake. In this profession, they call that “circling the drain.” I’ve seen that look at least a thousand times now, and I think I’ve only seen anyone come out of it twice in the last six years.

Even now, whenever I drive past that hospital, or that train station, I still remember that day in late June. The heat made the streets seem to waver, and I felt like I was floating along in some kind of surreal nightmare.

Walking from the Chinatown Gold Line station to the doors of that hospital. Those were the loneliest, most onerous two blocks of my life, and will probably be the benchmark by which I measure all my future suffering.

Death smacked me straight in the face one random January morning in 2007. You see, phone calls before 5 a.m. are almost never good. No one wins the lottery or gets engaged before 5 a.m. Sure, someone could have had a baby, but you usually know this in advance. You usually have some sort of warning. So when I got that pre-5 a.m. phone call straight out of the blue, I remember shivering. Hesitating about calling back.

Overcoming my dread, I call my cousin J. He tells me that his sister D is in the hospital. She’s intubated and sedated. (Reminding me of all those dreary progress notes I’ve written while rotating through the unit, trying not to kill anyone faster than they were already going.) What are you supposed to say, then? Not knowing anything about anything, just knowing that someone you knew and loved was dying, and quite possibly dead. Soul evacuated. I’m not here. This isn’t happening.

The last thing I ever said to her was that we should all hang out more.

I still get the shivers when I drive past the parking lot where we last parted.

Every day that passes, I feel like I’m just waiting. Whenever I see my dad slumped over on the sofa, having fallen asleep while watching TV, breathing quietly, I end up think about the fact that all our days are numbered. I know that we’ve got to make the most of every moment we’re given with each other, but at the same time, we’ve got to live in the present, with plans for the future. It doesn’t make any sense, really. I try not to think about any of this, but the longer I hold it in abeyance, the more likely it’s going to wake me up in the middle of the night, leaving me drenched in sweat, with my heart racing.

If I use all my strength up to swim away from shore, what are the odds that I’ll actually make it back? If I spend all that time now, what happens to later? Does it matter?

Eventually I end up quantifying how much anyone has ever loved me, which is an awful, ugly exercise. It’s like a Goldilocks and a three bears situation. I know for a cold, hard fact that my mom loves me. I know this more than I know that the stars that glimmer in the midnight sky are balls of hydrogen and helium gas. But there’s probably such a thing as too much. I’ve lived under her shadow for too long, letting her shield me from the real world, and now that I know that it’s all been a big mistake, a massive clusterfuck of epic proportions, it’s too late. I’m a mama’s boy. There’s nothing to be done.

Now my dad. My dad is not a virtuous man. Last weekend on Father’s Day, my sister gently chided him for all the things he did when we were all younger, and really, for all the things he didn’t do. My dad is a passionate man, but he doesn’t know how to express it. I’ve learned a lot about distance from him. About keeping your cards close to your chest. About never giving away a tell. In cards, in mahjongg, in basketball. The problem is, you can’t just hide things from your opponent. You end up hiding things from your teammates, too. You have to hope that they know you enough to still trust that the things that need to get done, actually get done.

My dad has committed his share of betrayals. Sometimes he simply wasn’t there when we needed him. But I guess the thing that evens it all out is that, in the end, he stuck around. As paltry, as pathetic as that is, I suppose it makes a difference.

The only two people in my life who probably give a shit about my sorry ass are my siblings. For better or for worse, we’ve travelled down a common path for decades. We’ve had our share of fights. A lot of them physical and violent, to tell the truth.

My brother is a lot more like my dad than I am, although we have the same penchant for distance. The only thing is that we’ve been through a lot together, and that’s probably all we can hope for. I honestly wouldn’t be surprised if my brother ended up getting married without telling me, or moving across the continent. It’s just the way we are. We’re brothers, and that’s probably as far as I’ve ever thought about it, for better or for worse. I don’t expect him to look up to me like I’m some kind of saint.

My sister. Well, that’s complicated. We’ve had an embattled relationship from the start, I think, striving for attention and control. Anything that my sister knows about politics, organizing, and sheer manipulation can probably be traced to the lessons of her youth from our sibling rivalries. Even today, we have long drawn out arguments that lead to shoving and hitting. I haven’t talked to her in three months now. I just don’t have anything to say that wouldn’t be patronizing. I’m not going to apologize. Even if I am wrong. If she needs me, she knows where to find me, and that’s that.

So much for living in the present, huh? Those are the four people I love the most on this green Earth, and it’s ridiculously complicated, and not a little painful. But I remember that quote about trying to stop a war being like trying to stop a glacier. I just ain’t gonna happen.

Oh, I’ve got friends who keep tabs on me from time to time. Mostly to make sure I haven’t imploded. I owe them far more than I’ve ever given them, if I’ve even given them anything worthwhile. And then there are those episodes that I like to think of as lost chances rather than abject failures. But we’ll never know now, will we? Somehow I stumbled upon some pictures I took with Chrsc., remembering that she’s getting married in about a year.

On bright days like this, the sunlight suffuses everything with a haze that gets embedded in my memories. These bright photons will fade with time, leaving impressionistic etchings on the walls of my mind. All I’ll remember is that it was bright and sunny.

Only the loneliness, the emptiness is real. It’s the only thing I seem to be able to touch, hard and sharp like forged steel.

Where do I go from here? That seems to be the eternal question. After all this time, I no longer want to know the answer. Times like this, all I want is some reassurance that I won’t have to suffer too much before the end.

I keep thinking about the cruel arbitrariness of the back story—how a beautiful fairy shows up dressed as a hag, and the prince is disgusted and throws her out. OK, so judging people by their appearances is not a good thing, but to use it as a pretense for turning a guy into a hideous monster makes me want to kick the fairy’s ass.

I’m thinking that what really happened was that the Beast caused his own curse. I can see it now. The fairy is someone he had fallen in love with, but because he never really loved himself, he has no way of winning her heart, and he slowly turns into the beast he imagined himself to be. Because shit like that tends to happen around fairies, you know? Latent death-wishes have a way of becoming reality sometimes.

The fairy—who just doesn’t see the Beast in that way, because, well, he’s kind of shallow and harbors way too much self-loathing, you know?—can’t do anything to undo the curse, except she realizes and tells him that he’s got to love himself before he can love anyone else.

Because just being friends with someone whom you’re hopelessly in love with is way too painful, the Beast and the fairy end up parting ways, and there he is, brooding in his castle, sadder than ever because there’s no way anyone is going to love him the way he is.

Of course, as the kingdom decays and because they didn’t have the Internet or Snopes in those days, everyone thinks the fairy actually cursed him, and uses the story as a way to scare the crap out of their kids.

Talk about pseudo-autobiographical. Sheesh.

My dad relates this anecdote to me:

Doctor: What is this stuff in your ear? It looks like a melted glycerin suppository!

Patient: Damn. No wonder I still haven't been able to poop. At least now I know where my hearing aid probably is.