Friday, June 17, 2011

With A Little Help

Friends. The family that we can choose, some say. You can't live with them and you can't live without them, others say. I've heard, "I don't know why I am still friends with them!" and I've heard "I don't know what I would do without my friends." The comments and feelings stirred among people when talking about their friends run the whole gambit of emotional investments.

I was thinking the other day about my various groups of friends, searching for the commonality that they all hold.  I have friends from my childhood and high school, friends from college, friends from medical school, friends from residency years, and friendships built from our life in this same town we have lived in for the past 15 years.  Because my wife and I settled into a city where our closest relatives live two hours away, our friends hold even more weight in our lives for the part they have played, sometimes even physically and mentally substituting for our family on special occasions.

Yes, we all need friends.  Better yet, we all better damn-well appreciate our friends. A good friend, tested and true, will be there through the pretty and ugly, through the happy and sad, and through the fun and miserable life moments.

I came up with a lot of reasons for the friends I have chosen or have chosen me over the years.  First and foremost, I like people that don't take themselves to serious.  After all, life is not such a stellar example of structure and order, and through the many moments of a typical day where something can go unexpectedly wrong, I like the person who can adapt with the situation and laugh off the change in plans.  So you thought you were going to be going to NYC for the weekend but your car broke down in the Poconos?  If you check in a motel and enjoy the Poconos, I like you.  If you bitch and whine and obsess over your ruined plans, I really hope to not spend more time with you in the future.

Diversity.  A key commonality among my friends.  My best friend growing up was Himer, an awesome buddy throughout our school years, classes and school sports and first dates and all.  His parents were much more liberal than my conservative parents, and somewhere between our different upbringings, we found a common bond of friendship.  My roommate all four years in college?  Christopher, straight from the rat-race we call Long Island.  Me--country boy, small-town, Adidas shorts and Hanes t-shirts, sneakers.  Chris--city-bred, big-town, Ralph Lauren pressed khaki shorts and purple shirts, penny-loafers. I took him four-wheeling and he took me to Manhattan. Oh, I can't forget about Gailie, my fellow Biology buddy who was a Catholic princess, through-and-through. Together, we were inseparable (along with Tony and Barnes and Dave) for much of our college days.  Best friend in medical school?  Easily KT, a Jersey girl with a heart of gold and an eye on public service.  We shared a bond of tennis and creative writing among many other things (including who to trust and distrust in our competitive class).  My best friend in residency?  Tomer, my Jewish, sharp-witted, cowboy-boot-wearing buddy for always, who watched my back during our 30 hour call-days.  Thankfully, sprinkled among all of these friends were more and more friends who impacted my life.

Even in my city life now, I surround myself with diverse friends.  Some of my best friends from the creative world?  A very cool, committed couple named Christine and Marcy.  Not only did they foster my love of the writing world, they also fostered my love of pets, of wine in quantity, in music, and in myself, helping me seek out ways to make myself better through some trying times.  My other friends all hold some diverse characteristics within their personalities that keep me coming back.  I love the fact that I do not seek "like" individuals, but rather people that can teach me and open my eyes to the many beautiful differences of their lives from mine.

Finally, without a doubt, the biggest commonality among my friends is humor.  Straight-up.  If you laugh at my silliness and I laugh at yours, we will be friends.  Prank phone calls, crazy texts, recognizing life's many absurdities, morning "sore-face" after a night of frenzied laughing and joking over a bottle of wine--those are the friends I gravitate to. Inappropriate and risque perspectives will get you bonus points, even.

Just last night, we were at an amazing dinner with six friends, eating great food (thanks, Michele!), drinking great martinis (thanks, Eric!) and wine, and just laughing and howling for four straight hours. No subject was off-limits and by the time we were hugging our goodbyes, we had solved most of the world's problems. Driving home, my wife and I both noted just how much fun we have with our friends. We are blessed to be surrounded by such cool people.

A better example?  Here is a reference letter our good friend Mike wrote for my wife when she was applying for a full-time position in a local school district.  It is just a rough draft, but one that he thought "might just get her the job."  Thankfully, he got serious and started at square one again, producing the perfect reference letter needed.  However, I tend to agree with him that this original letter may have gotten her the job in a much quicker fashion:

Dear Mr. K.,

I am a writin this letter to let you know that Karin is an awsim persin who would be a great choic for your new secretary girl. She haz a nice houz and drives a really cool bug! Her kidz are nice too and are clean most of the time. She haz good toes and a strong back. Lord knowz shez been carryin that husband Jim of herz  for years. She must be an angel from heven to be able to put up with his bull-shit, so she certainly can handle workin for you.

Karin is a great cleaner and bakes good tastin stuff. At a party once she made these reelly good brownies that made us feel reel mello. She must have a majik touch! Jim would never know that because he is always suckin down his fancy vodka drinkz. I think if he were smart enuf he would have hiz own moonshine still. I’ve only seen Karin reely drunk a few times so you don’t have to worry about her.
Karin is a reel cool mom too. She lets her kidz eat all the candy that Jim buyz at Sam’s Club and they still have most of there teeth. I bet those kidz will even gradute high scool one day despite the upbrigin of there pa. He has good intentionz but is a bit misgided when it comes to raisin youngins. I think he waz born in the woods or somthin.

Karin is good at managin stuff too. She can go to work all day then come home and cook and clean and get those kidz where they need to be…all the while Jim is “gettin his nap on”. It is amazin that she keeps that guy around. Allthou he is sorta pretty and has a nice set of gunz on him. I did see him without hiz shirt once and wuz amazd by what wuz there….. but this iznt the time to go into that!

Karin is reel easy on the eyes too. She would add some class to that school buildin. She haz nize hair, skinny ankelz  and amazin elbows. She smellz nize too. I bet she showerz almost every day and usez fancy lotionz. She certinly would not smell up the place.

Well, I hope you hir Karin for the job despit any shortcomins of her husband. Maybe he won’t come to the chrismas party so you wont have to meet him.

This made me laugh for days.  And days.  Only a good friend would waste an hour of his time to pull something like this off, right?  By the way, my payback to him?  Threatening to put his innovative letter on my blog and actually going through with it!  Didn't think I would do it, did you Mike?

Appreciate your friends.  Appreciate your acquaintances.  Appreciate the people around you who bring good humor, diversity, and a light-perspective to balance the seriousness that life sometimes holds. And appreciate the reflection of you that is mirrored back by all of your various friendships--this insight may prove to be invaluable and priceless.

As for me, I'll just keep laughing and smiling my way through this journey we call life.  With a little help from my friends, of course.  

As always, big thanks for reading... do you recognize the common thread that runs through your various friendships? Please share... and Happy Father's Day to all you fathers out there, especially those who treat the title of "Dad" or "Daddy" with the utmost are a heroes, each and every one of you.     

Friday, June 3, 2011

To Like Or Dislike

I was shocked by her appearance. Although she was in her early 50s, she looked closer to 80.  Matted peroxide hair.  Dull, lifeless eyes.  Sagging skin and deep wrinkles.  Protruding cheek bones.  Cracked, dry lips with a hint of yesterday's lipstick caked in their corners.  Gray and yellow-stained teeth, some chipped. In her prime and before alcohol and cigarettes became her every thought, I could imagine an attractive, lovely woman.  Now, sadly, what sat in front of me on the hospital cot in Room 12 was nothing short of a shell of a human being.  This was a woman who lived a hard life.

She had presented to our ER in respiratory distress.  Although she already had an established diagnosis of emphysema, she continued to smoke two packs of cigarettes a day.  On top of this, she had just finished a ten-day drinking binge, the last five of which she spent either passed out or drinking.  She claimed to have not eaten in that time.  I was called to her room because she was in such dire respiratory distress.

"Maam," I said after introducing myself, "how long have you been having trouble breathing?"  She was gasping for air, her nasal folds flaring with each struggle to breath deeply in.  Through her thin hospital gown, I could see her ribcage and diaphragm heaving, compensating for her non-compliant lungs, trying to pull that extra oomph of air into her body.

"I...don't...know," she managed to answer, each word a struggle for her.  Her hands, I noticed, were pale, their spidery veins popping through her thin transparent skin.  They gripped the top rail of the cot for dear life.

Immediately, I ordered breathing treatments.  Steroids.  BiPAP (a machine with an attached mask that would force supplemented oxygenated air into the patient's lungs every time she initiated a breath).  Blood work.  A stat chest x-ray.  The rapid intubation kit and ventilator for stand-by.  I asked more questions, questions she could answer simply by nodding her head.  "If you get worse, maam," I spoke, asking the most important question of all, "we may need to insert a breathing tube into your lungs, hook you up to a ventilator, and do your breathing for you.  Do you want that if it comes to that?"

A "yes" nod.  She tried to speak.  "I've...had...that...before," she gasped.  "You've been intubated before, maam?" I repeated.  She held up two fingers of her left hand in a peace-sign.  "Twice," she said.

Within the half-hour, surprisingly, she began to turn around for us.  I spent considerable time in her room during this period, making sure she would not decompensate before our eyes.  With the additional attention of two stellar nurses and a respiratory therapist at bedside, she thrived and slowly improved.  Finally, as her lungs began to fill with more air, her nasal flaring and ribcage retractions subsided.

After stabilizing her breathing, we began to treat her other problems.  For malnutrition and dehydration, we gave her several liters of normal saline and a "banana bag," a liter of fluid supplemented with thiamine, folic acid, and multi-vitamins, giving it a yellowish-color.  For her withdrawal tremors, we gave her Ativan, a longer acting valium-derivative.  We fed her ice-chips.  We gave her anti-nausea medicine and several low doses of pain medication for her evolving alcohol-induced pancreatitis.  Her chest x-ray revealed pneumonia in both lungs, and we began antibiotics to cover her for the common community-acquired organisms as well as for aspiration organisms (only God knew if she swallowed some puke into her lungs).

Finally, after a lot of attention and energy given to her, she was at the point where I could sit down a few extra minutes with her, making sure I understood all of her history and didn't miss anything.

"Maam," I started, "have you ever tried to quit smoking?"  "Yeah," she said, her voice now a little stronger, more gruff, "but I don't really want to.  I like it."  She looked at me with challenging eyes as she said it.

"And maam," I continued, "do you consider yourself to be an alcoholic?  Have you ever had treatment for it before?"  She answered immediately.  "No, I'm not an alcoholic.  I like my booze, but I don't drink nearly as much as my husband.  Now he's an alcoholic.  But I'm not."  She enunciated "he," spitting out the word like it was poison.  Her denial was remarkable.  And expected.  "Do you want help while your hospitalized for your drinking, then?"  "Why," she asked me, "if I don't have a problem?"

I asked her about abuse.  She denied physical abuse but claimed "that he yells at me a lot."  Again, she refused to accept any counseling.

Finally, as I was finishing, she said "Can I ask you a question, Doctor?"

"Of course you can, maam," I said.  "What can I do for you?"

"Well," she said, "I don't understand why doctors can't take care of my problems.  I don't like coming here all the time for belly pain and breathing problems.  Why can't they just get it right the first time I come in?"

I was shocked.  Completely and utterly thrown off my game.  Hackles up.  The nurse, standing at the room counter with her back to us, writing on her chart, turned her head around to face the patient, her mouth gaping and shoulders tightening.  I'm sure mine were, too.  Although we don't expect appreciation, we certainly don't expect to be blamed for a patient's medical problems, either.

"Maam," I said in my calmest , most respectful voice, "you have emphysema and, yet, continue to smoke two packs a day.  You have pancreatitis and, yet, continue to drink.  You completely ignore your body's needs, not drinking water or eating food for five days.  You are hacking up phlegm and don't use your inhaler or pursue treatment of these symptoms, resulting in pneumonia.  You've been intubated twice and have come to the ER multiple times.  And you can't understand why your doctors 'can't take care of your problems'?  Have you considered that your problems might be from your own poor decisions?"

I stopped and stared at her.  She stared back.  I waited for her to speak.  I was going to stand there all day if I had to.  Finally, with the nurse now standing along her other side, the patient spoke.  "I guess you are right.  Some of these problems are my own fault."

"Not some of them, maam," I said, "all of them.  By accepting personal responsibility for them, though, maybe you can move on and start treating yourself and your body a little better."  Although I'm sure my words fell on deaf ears, I still needed to have my say.  Especially when we all worked so hard to turn this unappreciative patient around from her multiple medical problems, some life-threatening.

I grabbed the patient's hand.  "Listen, maam," I said, "I wish you well.  I want nothing but the best for you.  But if you don't change your habits, I am sure I will see you in our ER again.  And again.  And, one of these times, I fear, we won't be able to undo your problems."

I let go of her hand and turned to walk out the door.  She was admitted to the ICU and was going to be transported up shortly.  Before leaving, though, she called out.  "Doctor!"  I paused and turned around.  "Yes, maam?"  She hesitated before speaking.  "Thank you for your help today.  I'll think about the counseling, okay?"

I nodded to her.  "Good luck," I said before continuing out the door.

One of the most frustrating parts of my jobs is dealing with patients' frustrations of their medical problems, simply because of their lack of personal responsibility.  It's rampant, too.  I cannot cure patient's who do not put their own effort into their health.  None of us in the medical field can.  We are here to help you along your journey, to walk sided-by-side with you in your, hopefully, healthy path.  Of course, some people do everything right, by the book, and still have medical issues.  That's different. But if you want to eat profuse and bad meals, please don't expect us to cure it with a simple "sugar" pill. If you want to eat fatty and greasy foods, please don't get pissed at us when your cholesterol pill isn't helping.

I love my ER patients.  Seriously.  I have met some very cool people over the years, from both different and similar walks of life, simply from what I chose to do for a living.  I appreciate and enjoy learning the diverse stories that rest behind their faces.  Sometimes, though, I get frustrated.  We all do in the medical field.  At the end of the day, we are all human, whether we perch ourselves on a pedestal or not.  And, regardless, we want the best for you, the patient.

To my patients that have made my job rewarding, a simple thank has been my pleasure learning about you and helping you on your healthy path.

As always, big thanks for reading...I hope this finds you all well.  Enjoy the weekend...