Quiet Time

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Not blogging much recently. I have started a new job with a vaguely familiar EMR that is known for being less than user friendly. RPMS is unwieldy, but anything is better than NextGen, although nothing is as wonderful as EPIC. I am adjust to being home and still not completely unpacked and settled.  My life is really so full of events, but no time to get them all down here. Soon…

Health Care Culture

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woman-fitting-in

I usually find a way to fit in a new job pretty quickly. Years of working as a locum tenens makes fitting in a survival skill.  I am surprised that I am feeling a little more guarded than usual. A friend of mine would call it “well defended”.

So much of healthcare is cultural. In some places every one handles colds in one way ( everyone gets a ton of medications) and in some places, we recommend tea, honey and rest.  In the first weeks I am in a new place, there are always folks who misunderstand my “style”.   With some patients I have to WORK really hard to convince them that I am really on their side.

Then, there is the whole culture of handling urgent issues.  Some places have protocols- anyone has a blood pressure greater than 180/90 gets the 911 treatment, no matter what the provider thinks is right.  Some place rarely send anyone to the ER and try to handle everything possible in the clinic.  Today was one of those days of explaining that I know what I want to do with this young patient, but I need to know how this clinic handles things. Labs/imaging and then to ER, or just skip it all and send to ER. Direct admit? What goes with her? Do I print the note, or write a new one on a script?

Some clinics work as a team, while some are just people in the same building without much interaction. Some folks are much more serious, some laugh and goof off all day between patients.  I am trying to find out where I will fit in this new place.  I feel “stressed out” trying to adjust. I am trying so hard not to be too much of me. I am working this time on having unspoken thoughts.

But, somehow it ends up like this…

ballet

( I am also trying to let go of wanting things to be perfect- like blogging.  )

Chronic Pain

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I don’t know why I am so immersed in this subject right now. It is just the way that my brain works. I am reading every book that I can find right now. I just can’t get enough knowledge about chronic pain syndromes.

When I go through these periods of fascination, I am hyper focused. I read books, listen to audiobooks, tear pages out of journals, search the net and pod casts for information. I am following a few blogs of folks with chronic illness.

The hardcovers just arrived to compliment my Kindle and Audible copies of  Nation in Pain, The Emperor’s New Drugs and Being Mortal. I am still wading through How to Manage Pain Before It Manages You.

We had a discussion today about Arthur Boorman from the “Never, Ever Give Up” video.  In my opinion the video should be playing on endless loop in every medical office in the United States.  None of us really understands how to help people find the sort of motivation and courage that Arthur shows.  We all agree that “ganas” is the most important thing. Without it, nothing improves.

What motivates you? What inspires you? How do you motivate or inspire others?

Not Work Related

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Garden maze

Sometimes, I completely forget that my life isn’t just about work.  One of the many joyful things in my life is my 1950’s ranch house that sits on about 1.5 acres or so.  For reasons, I no longer remember, I decided last year that I would copy this lovely maze that is probably much better suited for the English garden where the original grows.  I know NOTHING about geometry and I cannot ever make anyone understand the depths I will go to avoid math.  Still, I thought, how hard can this be? I couldn’t make the maze print onto graph paper no matter how I tried, so I made it the size I wanted on my computer screen and traced it onto graph paper right from my computer screen.

This should have been a clear sign that I should just go to Bridge’s End, in England and enjoy it there. But, nooooooo.  This will be fun I thought. After all, anyone can make a raised bed garden right? Why not make it ridiculously difficult? So, I have started over many times. Moved the boards around more times than I can count. Finally, I understood that I should use a ruler to measure sections on the graph paper before just “eyeing” it and trying to make it fit. I learned that a 45 degree angle on the paper is still a 45 degree angle on the ground. I learned that one should take into account the thickness of the boards when measuring.

I have learned that other folks will sometimes volunteer to help me.  I think it is such a weird thing to do they just want to keep an eye on me as they wait for me to show further signs of mental instability. I know that we will usually end up arguing over the proper angle or length of boards.  As many times, as I have started over, and argued with whomever is helping me over where we should put the next board, it is still fun.

Today, after a year of working on this thing off and on when I am home, I finally figured out where I keep screwing up and began the long process of moving things about again. I used a ruler and a I think it is called a protractor to draw it out on graph paper after I realized that I cannot make it fit exactly like the one in England.  But I took a very long time to make the proper adjustments on the graph paper to keep true to the maze.

I feel happy about the whole project and hope to complete the upper half this year. Raised beds from recycled 2×6 redwood fence. This is fun. This is fun. This is fun.

At the same time, I am working on making a chicken coop, getting the above groung pool ready for summer, planting and starting seeds, pulling weeds and countless other projects all at the same time.  Life is just so full of event right now. Not all of them are work related.

Chronic Pain

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Chronic Pain

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I was half listening to my latest audible book on the way to my first day of orientation at the new job. I say half because it is probably the 3rd time through those last few chapters. It isn’t because the book isn’t holding my attention, it is just it is one of those books I am talking back to as I drive and listen. It is one of the books that I will order in print and highlight and take notes in the margins.  I will review the book in more detail in some future post.

But she said something that had me wanting to scream.  She said that not treating patients in chronic pain amounts to torture.  I may be assuming too much, but it seems she was overly emphasizing opioids as a treatment for chronic pain. Firstly, opioids suck at treating most chronic pain and cause many more problems that they solve most of the time. Secondly, no one has a right to a pain free life. No one.

I was getting all judgy, as I am wont to do. Talking back to the book.  Really? Torture?  How is it my fault that you smoke, don’t exercise, drink like a fish, are 75 pounds over weight and now your knees and back hurt? Really? Sounds like that chronic pain is on your side of the net that divides us in this debate over opioids. I am not going to continue every patient in pain on the unholy trinity of Norco, Soma, and Xanax.

Then, doing my best Tevye impression ( from Fiddler on a Roof), I said, “On the other hand”, What about the obese, sedentary smoker who needs medication to control their blood pressure and blood sugars both of which are out of control because of their lifestyle choices? Do I want to say, No more Metformin for you unless you start exercising? No. Of course not.  But on the other hand, I don’t see Metformin sending the patient down a slippery slope of every escalating medications with all motivation sucked out of them now do I?

I should hold off my opinion of this book until I finish it completely.  I am finding it to be a fascinating if not somewhat biased account of the state of chronic pain diagnosis and treatment.  As loud as I shouted in the car at the author, she did not respond, so I am just venting a bit here.  Torture and not giving opioids to every chronic pain patient are entirely different things. Seriously.

I am not just frustrated with the patient, I am more upset with the system that got us on opposing sides in the opioid wars.  We all know it doesn’t work to just give folks opioids. It is so much more complicated than that.  Pain management is always a trial with an “n” of 1.   Each person is different.  Even that one person is different on a day to day basis.  Not giving out opioids to every patient is NOT torture.  Please review the history of any war of your choice to get a much clearer idea of what torture is and is not.

Crying

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crying

I was reading over on Kevin, MD about a photo that was captured by a paramedic. (http://www.kevinmd.com/blog/2015/03/why-did-this-image-of-a-crying-doctor-go-viral-heres-why.html )  The photo shows a young doctor crying over the death of a patient.  The photo has generated quite a lot of internet buzz.  Should healthcare providers cry? Does crying make us unprofessional? Are we supposed be detached? What kind of person is able to remain emotionally detached doing what it is that we do?

I am not sure if it is a nurse thing or not. I cry.  I cry in front of patients. I cry with patients. I cry with families. My last cry was happy tears while hugging a patient who had been told that the diagnosis of “metz” to his lungs was a mistake and he was going to be just fine.  Yes, I cried with him when he got the original bad news.

I cry because I genuinely care deeply. It makes me a good provider for the most part. It makes me sit up reading every thing I can find that might help.  Sometimes, there is nothing I can do but care about the other person.  Sometimes that is the most important thing.  Being human.

I laugh with patients. I joke with them.  I encourage. I tease. Sometimes, I am the ice princess.  But that is rare.  The emotions I don’t share are angry ones. At least, I try not to let it show that I would like to dump a glass of ice water on the head of a patient that is yelling at me or insulting me.  So, there are limits to being fully expressed.

It makes me sad to read about physicians being expected to “suck it up”.  I imagine all that compartmentalizing is crazy making and it may be one of the reasons that physicians have such a high suicide rate.  I don’t know why their training is so harsh.  I don’t think it makes them “better” as health care providers.  Their crazy high divorce and suicide rate should let them know it isn’t good for their health.

Do you remember Rosie Perez in White Men Can’t Jump? I love the part where she was trying to explain that she didn’t want the boyfriend to get up and get her a drink of water when she said she was thirsty.  She could get it herself.  She wanted him to just understand or care. She wanted him to say ” I too, have been thirsty”.  Sometimes, our patients don’t want a pill or advice. Sometimes, they just want someone to say: “Yeah, parenting a teen was so hard for me too”.

I hope that more physicians are talking about the “disconnect” from emotions. I hope that they start encouraging each other to talk about their feelings long before they consider suicide.  I think of all the young residents that I knew while working in that huge hospital.  It breaks my heart to think that they will feel so isolated from the rest of the world that they think that sedation or suicide is the only way to cope.

One of the physician blogs that I follow is “Behind the White Coat  beats a real human heart”.   We all need to keep that in mind, don’t you think?