Tuesday, December 27, 2011

Physician, Heal Thyself!

     Once you become a doctor, especially if you're an anesthesiologist or a surgeon, you abdicate the "right" to be sick. You may have a fever of 102, purulent green sputum, and a cough which causes your colleagues to run and hide in fear of droplet contamination, but if you don't come to work, who's going to take care of the patients? When I first became an attending physician, I had an upper respiratory infection which lasted for 6 weeks, and my office mates were all seriously worried that I'd contracted tuberculosis. You could hear me coughing all the way down the hall. Once I'd get started, I couldn't stop; it came in paroxysms. If I was able to stop coughing long enough, I could feel myself wheezing, so I started bringing one of Nick and Rory's albuterol inhalers with me to work to calm my irritated small airway passages down. It appeared to be a nasty combination of bronchitis and a sinus infection, but the Z-pack (antibiotics) I called in didn't seem to make much of a difference. All I got was a bad case of the runs. God only knows what my patients thought as I coughed and wheezed my way through their pre-operative exams.
     From the moment we begin our medical training, it is ingrained in us that being sick is a sign of weakness, a state of being you must ignore. As a surgery intern, I remember starting an IV on one of the 3rd year residents on my team at Grady. He was so pale and sick that he could hardly stand up. As we sat in the break room, waiting for his bag of fluid to run in, we were stat-paged for a trauma down in the ER. We all took off, sprinting down the corridor to answer the call, and he was right there with us, running with his IV pole in hand. I worked with another surgeon, who became so sick during one of his procedures that an IV was started on him, right there in the operating room. He let the chief resident finish the case, and because he was feeling better from the hydration, went to the lounge to have a snack. He returned to the operating room, where he sat down next to the anesthesia provider, hanging his fluids adjacent to the bag connected to the patient. The anesthetist was busy, preparing the patient for transport to the ICU. Somehow the IV tubing got intertwined, and the surgeon ended up receiving a paralyzing dose of rocuronium, intended for the patient. As he hit the floor, his IV dislodged, and he had to be intubated, completely paralyzed but awake, with a full stomach, while someone tried to start another line. It seems that if you're sick enough to require an IV, you really should just go home and recuperate. The unfortunate outcome of this "rule" against being sick is that physicians become masters of denial in matters concerning their own health, and this, I believe, has an impact on how we care for our patients.
     Before Brad and I got married in October of 2009, we bought a couple of German short-haired pointer (GSP) puppies from a colleague named Cinnamon, who had bred her dog, Roxie. GSPs are a spirited, energetic hunting breed. They are loyal, affectionate, sweet-natured and incredibly intelligent. They grow to be anywhere from 45 to 75 pounds and are blissfully unaware of how strong they are; they just want to play. Simon and Lilly were two little brown bundles of activity, all paws and bobbed tails, constantly wagging. By the time they were 6 months old, both puppies had almost reached their adult weights. We had a special fence built for them around our side yard, one that they couldn't dig under or jump over, but being outside isn't enough for GSPs; they want their people to run and play with them. Neither Brad nor I had any experience in leash-training a dog, and Simon and Lilly pulled and tugged on their leashes like wild horses. The bigger they got, the harder it was to walk them, so eventually, we stopped trying. One day in January of 2010, Cinnamon and I decided to get together and take Simon, Lilly, and Roxie out to Stone Mountain, where she knew of some cool wooded trails. We thought the dogs would have fun, running around together off leash, down by the lakefront. Brad and I drove over to Cinnamon's with Simon and Lilly, and then, we piled back into our cars, with the three dogs in tow. I had really had a tough time with Lilly over at Cinnamon's. She was on the leash, and had gotten so excited by seeing Roxie that she nearly dragged me down the hill, next to the driveway. In the struggle to control her, I thought to myself, "This could get dangerous!"
     Once we arrived at Stone Mountain, Brad and I let Simon and Lilly out of the car. They were already on their leashes, so I took hold of both dogs and walked them a little way from the car, while Brad got their water container and toys out of the trunk. I had neglected to anticipate the mandatory period of excitement, a phenomenon which occurs regularly and predictably with GSPs. Whether you've been gone all day or just stepped out of the room for two minutes, these dogs are so thrilled to see you again, that they start running around in circles, ready to play. As Brad approached us, Simon and Lilly began to run in opposite directions, encircling my ankles with their leashes until they were pulled tight, and within seconds,  I fell backward like a giant sequoia, onto my right elbow. Tim-berrrrr! PLUNK! Crunch! The pain which shot through my elbow was exquisitely sharp, bringing tears to my eyes, along with several overwhelming waves of nausea. Completely stunned, I sat there, crying. I tried to get up, but was so unsteady from the pain that Brad and Cinnamon had to help me onto my feet.
     I must preface this by saying that, like my mother, I have an extremely high tolerance for pain. I rarely, if ever, need to take ibuprofen or Tylenol for anything. I had my wisdom teeth removed without the standard Valium pre-medication; local anesthetic and nitrous oxide were all I needed. I managed to survive my herniated disc without narcotics, and once the inflammation dissipated, with the help of prednisone, I started a walking and core-strengthening program, and now my back is fine. When Brad and I first started dating, we had a habit of making out in the woods behind his house. I broke several of my toes, on separate occasions, walking barefoot over pine straw covered holes and large twigs to get to the clearing where he was waiting, but rest, ice, compression, elevation, and buddy-taping saved me, no analgesics required.
     Cinnamon and I examined my elbow, which was filthy from the dirt and gravel I fell back on, but all we could see were two deep holes. I could flex and extend my arm, so neurologically, it seemed to be intact. There was no bathroom close by, so she got a first aid kit from her car, cleaned up the wound and bandaged it as best she could, and we decided to go ahead and let the dogs play. She showed us a way of looping the leashes around the puppies' hind quarters, which prevented them from pulling, making the walk with them a little easier. They dashed in and out of the water, even though it was cold, running at full speed up and down the sloping hills next to the river. On our way home that evening, we stopped by the drug store, and I bought all sorts of bandages, ACE wraps, Neosporin ointment, and non-stick gauze pads, so I could be ready for work the next day. I sat in a warm bath with Epsom salts, and then got Nick and Brad to help me irrigate my wounds with homemade saline, using an old Water Pik we kept under the sink. I think they were both pretty grossed out because the holes in my elbow were really deep, there was a lot of blood, and the nozzle of that Water Pik was halfway buried within the recesses of those two wounds. I bandaged my elbow, took four ibuprofen tablets, drank a couple of glasses of wine, and went to bed. The next morning, I got ready for work as usual. My elbow seemed to still be oozing quite a bit of blood, so I reinforced the dressing, and shoved lots of Neosporin up into the wounds. I put on my white coat and drove to work. I was supervising the acute pain service, and I started the day by observing one of my residents place an epidural. The patient needed a bolus of IV fluids, and as I reached up with my right arm to move the bag of fluids up to a higher position on the pole, I felt my elbow pop. It was a strange sensation, and it hurt a little bit, too. I started wondering if something really was wrong. I ran into Cinnamon in the pre-op area, and she, along with my team on the pain service, urged me to go down to the emergency room for an Xray.
     It was about 8:15 a.m. The breakfast I'd eaten at 5:30 was long gone, and I was hungry, so before heading down to the ER, I stopped by the anesthesia lounge to get a couple of packages of graham crackers. I went to the nurse's station, and awkwardly explained my situation to the head nurse. She immediately went and found one of the attending physicians, who examined me on the spot, and ordered a set of Xrays. I was ushered into a little room, where the nurse took my white coat, the right sleeve of which was stained with blood, and proceeded to start an IV and obtain labwork. This certainly seemed like overkill to me, but I obliged. I will never understand why she started the IV in my left antecubital vein (crook of the elbow) when I have huge, ropey veins in my hands and forearms. My veiny arms have always been a source of envy for the pre-op nurses: "I wish we could borrow your veins for this patient!" they'd exclaim, as they were struggling to obtain access on a patient who was a difficult stick. The IV was very uncomfortable and the tape used to secure it was itchy. I sat and watched morning television, texting back and forth with Brad, the boys, and the pain service team. Just as "The View" was coming on, the ER physician came in and told me that I had an open fracture of my right elbow. The tip of my elbow had shattered into several fragments, and the joint capsule had been breached. I was surprised about this because I hadn't seen any bony fragments, peering through the wounds. He congratulated me for having had the presence of mind to irrigate the wounds with the Water Pik, and then he told me, "You have to have surgery to fix this today. It's a surgical emergency." I knew that open fractures were surgical emergencies, but somehow, I didn't think it really applied to me. He had already consulted an orthopedic surgeon at the outpatient surgery center a couple of miles from Emory, and I was put on the schedule for three o'clock. I grabbed my white coat, which the nurse had tried to clean with peroxide, and with the IV still in my arm, went upstairs to my office. Judy, the assistant to the chairman of our department, offered to drive me over to the surgery center, so I gathered up my purse and satchel, and off we went.
     The next few hours are a blur. First, I sat in the reception area, waiting to go through the outpatient surgery admission process. Weird thoughts started entering my mind, and before long, I was preoccupied with whether or not I was going to have to remove my underwear for the procedure or whether anyone would see me naked. Most mortifying of all, what if I farted while I was under anesthesia? I used to help staff the surgery center, so I knew everyone who worked there. Heather, the main anesthesiologist and nerve block guru for the facility, was off that day, and another co-worker of mine from Emory was supervising Jenny, the senior resident who was completing her two week rotation there. Jenny was a personal favorite of mine, and I had helped teach her how to do nerve blocks when she rotated on the acute pain service the year before.
     Once I made it up to the pre-op holding area, things began to happen fast. Jenny assessed me, and told me the plan was to do my case with an axillary nerve block and monitored anesthesia care (MAC, or IV sedation). Matt, the attending anesthesiologist, reviewed my chart and Jenny's anesthetic plan, and started helping her assemble the supplies for the block. Brad arrived, looking worried, and sat next to me as I nervously awaited placement of my nerve block. I had no idea what it was going to be like to receive sedation, or to have my arm numbed up. Truthfully, I really didn't like being a patient at all. After I got 4 milligrams of Versed and 100 mcg of fentanyl, being a patient suddenly seemed less awful. Jenny used an ultrasound to perform the axillary block, while Brad and I watched. I don't remember much of anything after receiving the Versed. I remember not being to move my arm, and I vaguely remember being in the operating room. Apparently, I was quite chatty, and Jenny had to give me a little extra propofol to stop talking; it was starting to annoy the surgeon. The tip of my elbow was comminuted beyond repair, and the surgeon ended up having to reattach my triceps tendon instead, using a couple of anchors. I woke up in the recovery room, where the nurses had some ginger ale, and you guessed it, graham crackers, waiting for me. Brad drove me home, which was where I spent the next two weeks. I felt so good that I didn't take any pain meds, a direct violation of the advice I give all of my patients who receive nerve blocks. You want to have some pain medicine in your bloodstream before the nerve block wears off, so you can transition smoothly from one mode of pain control to the other. At 4:00 a.m., I woke up in excruciating pain, and spent the next 24 hours, nauseated from the discomfort, trying to make up for lost analgesia with Percocet.  In all, it was a 8 week recovery period. I went back to work after two weeks, but because I couldn't engage in any activities which required active resisted extension of my triceps, such as CPR, I couldn't work alone in the operating room. I spent the next six weeks, supervising the acute pain service, which was already one of my favorite assignments anyway.
     The worst part of my recovery was seeing my once super-toned right triceps go completely flabby. My vanity got the best of me, and I disregarded some of the surgeon's orders about exercising my elbow. I started using a rowing machine. I rationalized that it was OK, because rowing doesn't really work the triceps, nor does it involve any active resisted extension. Because of that, I now have chronic right elbow pain. I am no longer able to do big girl pushups; I have to do them with my knees on the floor. I can lift weights and do chaturangas during yoga, but I always feel it in my elbow afterwards, and it hurts. I still don't take any pain meds, and just limit my activity if my elbow really starts acting up. If I had to do it all over again, I think I would have followed the surgeon's orders to the T.
     The good news is that Simon and Lilly are now perfect-leash walkers, thanks to the professional trainer we hired following that fateful day. They follow commands, and are generally quite well-behaved. My broken elbow provided the impetus for us to help them gain some discipline. It also made me rethink my role as a healer. In Eastern medicine, healing is a function of body awareness and balancing the flow of Qi (chi or prana) or life force, whereas Western healing is focused on eradicating disease externally, through the use of medications or interventions. Intuitively, the Eastern model of medicine makes a lot of sense to me. It is health-centric, whereas Western medicine is disease-centric. In the Eastern model, the disease state is perceived as a loss of adaptability resulting from a disharmony in bio-energy, and symptoms, such as pain, are seen as the body's way of communicating that the life force is out of balance. Qi is central to Eastern medicine, and life and medicine are considered to be one in the same. In the West, symptoms are viewed as a nuisance or a threat, as something to be actively suppressed, because the focus isn't on body awareness, it's on stamping out disease. This lack of awareness goes hand in hand with the denial I alluded to earlier. If you're not attuned to your body's cues, how can you ever really be healthy? Pain and illness are signals that we need to realign our chakras, so to speak, to pay attention to the messages our bodies are sending us, and re-balance our Qi. I am spending much more time now, listening to what my body is telling me, focusing on wellness, and I am trying to carry this over into my daily practice of anesthesiology. I make time to talk to my patients about smoking cessation and losing weight: it's part of practicing compassionate medicine. I think that if Western medical students and residents received more exposure to the concepts espoused by Eastern medicine, we'd not only become more effective at healing our patients, we'd evolve into more compassionate physicians who are also truly capable of healing ourselves.

2 comments:

  1. Howdy,

    Just a random M1 who stumbled accross your site. I wanted to say I enjoyed this post. You're a great storyteller, and I agree with your final thoughts on the benefits of a health-centric paradigm.

    Have a good one,
    ADC

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    1. Hi there! Glad you found my site! Where are you attending medical school, ADC?

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